WebCMS-1500 Claim Form; Box 1 - Plan Type; Box 1a - Insured's I.D. Number; Box 2 - Patient's Name; Box 3 - Patient's Birth Date, Sex; Box 4 - Insured's Name; Box 5 - Patient's Address (multiple fields) Box 6 - Patient Relationship to Insured; Box 7 - Insured's Address (multiple fields) Box 8 - Reserved for NUCC Use; See more WebCMS 1500 Form telephone number. Item 6 Patient’s Relationship to Insured If Medicare is primary, leave blank. Check the appropriate box for the patient’s relationship to the insured when item 4 is completed. Item 7 Insurance Primary to Medicare, Insured’s Address and Telephone Number Complete this item only when items 4, 6, and 11 are ...
CMS Manual System - Centers for Medicare & Medicaid …
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Claim Forms: Billing Items & Modifier Codes - Box 24
Webcrossover, in Box 25 has been removed; • The requirement to report the PIN of the Skilled Nursing Facility in Box 23 has been removed; • Clarification language added to Box 17a indicating qualifier 1G precedes the Unique Physician Identification Number. B. Policy: The Form CMS-1500 answers the needs of many health insurers. It is the basic ... http://www.cms1500claimbilling.com/2011/01/cms-1500-24-g-days-or-units-24-f.html Webadjustment please refer to CMS 1500 Void and Adjustment Instructions. BLOCK 23 PRIOR AUTHORIZATION NUMBER (CONDITIONALLY MANDATORY) Enter the South Dakota Medicaid prior authorization number if applicable. Otherwise, leave this box blank. BLOCK 24 List only one servicing provider on each CMS 1500 claim form. Use a separate line for rules to writing a parody song