Cms 1500 Claim Filing Instructions (Page 3 of 9) in pdf

Cms 1500 Claim Filing Instructions Page 3

10abc

Required if

Is Patient’s Condition Related To:

applicable

Indicates if the services billed on a claim are related to or the

result of employments, auto accident or other type of accident.

10d

Not applicable

Reserved for Local Use

Required

Insured’s Policy Group or FECA Number

Group or FECA number for the subscriber of this policy

responsible for payment of this bill.

11a

Not Required

Insured’s Date of Birth, Sex

Subscriber’s birth date in MM/DD/CCYY format and his/her sex

identified by M (male) or F (female).

11b

Not Required

Employer’s Name or School Name

Subscriber’s employer name or name of institution where

enrolled.

11c

Not Required

Insurance Plan Name or Program Name

Plan name or program name of the policy responsible for

payment of this bill.

11d

Required

Is There another Health Benefit Plan?

Indicates if there is other medical coverage for the patient. If so,

please be sure to complete item 9a-d.

Required

Patient’s or Authorized Person’s Signature

Indicates if the provider has on file a signed statement permitting

the release of medical information to process the claims.

Cms 1500 Claim Filing Instructions Page 3