Tuesday, November 23, 2010

BOX 9C to 11C - Is patient condition related to field of CMS 1500

Billing instruction for Ambulance Billing - Box 9C to 11C

BlockNo. Block Name Block Code Notes
9c Employer’s Name or School Name A Enter the name of the other insured’s employer.
9d Insurance Plan Name or Group Name A Enter the other insured’s insurance plan name or group name.
10a-10c Is Patient’s Condition Related To: A Complete the block by placing an X in the appropriate YES or NO box to indicate whether the patient’s condition is related to employment, auto accident, or other accident (e.g., liability suit) as it applies to one or more of the services described in Block 24d. For auto accidents, enter
the state’s 2-digit postal code for the state in which the accident occurred in the PLACE block (e.g.,
PA for Pennsylvania).
10d Reserved For
Local Use
O It is optional to enter the 9-digit social security number of the policyholder if the policyholder is not the recipient.
11 Insured’s Policy Group or FECA Number A/A Enter the policy number and group number of the primary insurance other than MA.
11a Insured’s Date of
Birth and Sex
A/A Enter the insured’s date of birth in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and insured’s gender if it is different than Block 3.
11b Employer’s Name or School Name A Enter the name of the other insured’s employer for the primary insurance.
11c Insurance Plan Name or Program Name A List the name and address of the primary insurance listed in Block 11.

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