Friday, June 25, 2010

CMS 1500 - BOX 11: INSURED’S POLICY GROUP OR FECA NUMBER

If the member has a secondary insurance these boxes must be completed.

BOX 11a: INSURED’S DATE OF BIRTH AND SEX

If YES is checked in Box 11d, enter the month, day and year
the policyholder was born. The format for a birth date must be
MMDDYYYY.

Enter an X in the appropriate box for the policyholder’s sex.
BOX 11b: EMPLOYER’S NAME OR SCHOOL NAME
If YES is checked in Box 11d, enter the name of the policyholder’s
employer or school.

BOX 11c: INSURANCE PLAN NAME OR PROGRAM NAME

If YES is checked in Box 11d, enter the name of the policyholder’s
insurance plan or program. Do not enter Medicare or the name of
any State program.

BOX 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?


If the member is covered by other primary insurance
and he/she is not the policyholder, enter an X in the YES box
and also complete Fields 9a–9c. If there is no other insurance, enter an X in the NO box.

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