Sunday, September 26, 2010

Box 11 - Insured’s Policy Group Number

Item 11 is a required field for paper claims.

As stated in the CMS–1500 claim form instructions:

“This item must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to items 11A-11C.

NOTE: Enter the appropriate information in Item 11C if insurance primary to Medicare is indicated in Item 11. If there is no insurance primary to Medicare, enter the word “NONE” and proceed to Item 12.”

When box 11 is completed with a policy number, the following information MUST also be
submitted:

• Item 4-Insured’s Name
• Item 6-Patient Relationship to Insured
• Item 7-Insured’s Address
• Item 11C-Insurance Plan Name or Program Name

• A copy of the primary payer’s Explanation  of Benefits (EOB) MUST be attached.

The EOB needs to contain the primary paid and primary allowed amounts for the corresponding services billed on the Medicare claim. The EOB and the Medicare claim should have the same physician or supplier’s name or code, the same dates of service for the period of time over which the services were rendered and the actual charges for the services must be the same.


When an EOB is attached, the following information MUST also be submitted:

• Item 4-Insured’s Name
• Item 6-Patient Relationship to Insured
• Item 7-Insured’s Address
• Item 11-Policy Number
• Item 11C-Insurance Plan Name or Program Name

The following situations will also cause delays in processing claims:

*If Item 11 contains a policy number but the EOB is not attached.
*If the patient’s EOB is attached and Item 11 is blank or states “NONE”.
*If Item 11 is blank.

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