Insurance Form 1500 Secondary Insurance

Item 7 insurance primary to medicare insured s address and telephone number complete this item only when items 4 6 and 11 are.

Insurance form 1500 secondary insurance. This is per medicare cms 1500 requirements. Expiration date of 2020 03 31 pending o m b. Check the appropriate box for the patient s relationship to the insured when item 4 is completed. Notes comments addresses or any other notations in this area of the form will result in the claim being returned unprocessed.

If no private insurance is involved leave blank. All items must be completed unless otherwise noted in these instructions. If medicare is secondary and you choose to look at the cms 1500 box 29 will show 0 00 as the paid amount. Complete the items below on the cms 1500 02 12 claim form or electronic equivalent in addition to all other claim form requirements when medicare is the secondary payer.

To generate a cms 1500 for secondary insurance for a single date of service. Item 6 patient s relationship to insured if medicare is primary leave blank. To print a cms 1500 form for secondary insurance when the primary claim was submitted by edi go to the patient s chart under the patient billing tab. When you create a secondary claim electronically the primary adjudication information is embedded into the edi file.

Insurance is through a group such as an employer union etc. Cms 1500 form telephone number. Block 1 show all type s of health insurance applicable to this claim by checking the appropriate box es. See note 1 9b other insured s date of birth enter the secondary policyholder s date of birth and mark the appropriate box for the sex of the secondary policyholder.

Cms 1500 02 12 claim form instructions when medicare is secondary. Continue to use the current cms form 1500 02 12 beyond the o m b. This removes the need to send a copy of the eob to the secondary insurance. For medical assistance processing the top right side of the cms 1500 must be blank.

The center of medicaid and medicare services cms form 1500 must be used to bill sfhp for medical services. How to create cms 1500 for secondary insurance. Billing your secondary insurance company determining primary or secondary when you have two insurance companies that provide coverage for you it is important they know about each other. If no private insurance is involved leave blank.

Please complete and attach this form ma 538 to the cms 1500 for commercial insurance including the medicare advantage plans instead of attaching a copy of the commercial insurance eob to the cms 1500. Medical assistance recognizes that providers receive eob s from commercial insurance companies that do not always provide a claim line. Billing your secondary insurance company cms 1500 claim form and ub 04 form instruction and guide.