1500 Insurance Form Field 29

The center of medicaid and medicare services cms form 1500 must be used to bill sfhp for.

1500 insurance form field 29. Patient name from patient master. 1a required insured s id number identification or certificate number assigned to the insured subscriber. This can not exceed the member. Health insurance common claims form.

Field specification this field allows for entry of 29 characters. A cms 1500 with field descriptions and instructions is included in the link below. Enter the patient s full last name first name and middle initial. It is the basic paper claim.

Please submit complete number including alpha prefix. You must enter this amount on the claim form and you must attach the explanation of benefits. Instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness. 29 if applicable amount paid enter the amount of.

If the patient uses a. Patient dob and sex from patient master. Esa 29 dol esa 30 dol esa 43 dol esa 44 dol esa 49 and dol esa 50 published in the federal register vol. The third party amount must equal the actual third party payment plus any withheld amount shown on the insurance company s explanation of benefits.

A federal government website managed and paid for by the u s. Item number 2 title. The 1500 health insurance claim form answers the needs of many health payers. Cms 1500 form fields description field number description 1.

Patient insured of the destination payer in the insurance information screen under patient master. Claims for medical services. Cms hhs websites cms global footer. For a medicare crossover claim medicare replacement plan claim or a claim with no other coverage leave this field blank.

Cms 1500 claim filing instructions field locator requirements field description 1 not required type of health insurance coverage applicable to claim patient s type of coverage. Payer type of the destination payer. Enter the amount paid by insurance company third party. Expiration date of 2020 03 31 pending o m b.

All items must be completed unless otherwise noted in these instructions. Continue to use the current cms form 1500 02 12 beyond the o m b. Centers for medicare medicaid services. 29 situational amount paid.