Claim Replace Mandatory Field For Free

Box 9 indicates that there is another policy that may cover the patient. The insured's name is entered as Last Name, First Name, Middle Initial, separated by commas.

Box 17 identifies the name of the referring provider on the claim. Enter the applicable qualifier to the left of the vertical dotted line to identify which provider is being reported.

57. Other Provider ID. Enter the correct 7-digit provider number as assigned by Medica. for the type of services provided. RA.

The Patient Status Code (Form Locator 17 on the UB04 claim form) identifies patient status as of statement covers through date and is required on all Institutional Inpatient and Outpatient claim types.

Item 17a Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.

12 Patient's or Authorized Person's Signature Yes Enter the patient's or authorized person's signature. Signature on File or "SOF" are acceptable. If the claim is for a Lab or DME provider "No Signature on File" or "Patient Not Present are also acceptable."Signature on File or "SOF" are acceptable.

Description: Box 33 is used to indicate the billing provider's or supplier's billing name, address, ZIP code, and phone number and is the billing office location and telephone number of the provider or supplier. Enter the provider's or supplier's billing name, address, ZIP code, and phone number.