be marked. If the gender is unknown, leave this field blank. 4/1/2014 Field now 9c Reserved for Enter the name of the other Not required reserved for NUCC Use insured’s employer or school. NUCC use. 4/1/2014 Field no 10d Claim Codes If submitting a Medicare Not required. MassHealth member longer (Designated crossover claim, enter the identification (ID) is captured at available for by NUCC) complete 12-character member field 1a. MassHealth identification (ID) number that use. is printed on the MassHealth card. 4/1/2014 Changes to 11d Is Enter an X in the appropriate an X in the appropriate box instructions for Another box to indicate whether or not to indicate whether or not there is completing the Health Benefit there is another health benefit another health benefit plan. If Yes, field. Plan? plan. If Yes, complete Fields 9 complete Fields 9, 9a, and 9d. and 9a through 9d. Make an Make an entry in only one box. entry in only one box. 4/1/2014 now 14 Date of Enter the start date of the present Enter the start date of the present requires a Current: illness, injury, or condition in illness, injury, or condition in qualifier. Illness, Injury, MMDDYYYY or MMDDYY MMDDYYYY or MMDDYY or Pregnancy format. format. (LMP) For pregnancy, use the date of For pregnancy, use the date of the the last menstrual period (LMP). last menstrual period (LMP). one of the following qualifiers to indicate which date is being reported: 431: Onset of Current Symptoms of Illness 484: Last Menstrual Period 4/1/2014 Field name 15 Date Not required Enter another date related to the changed and patient’s condition or treatment in field is now MMDDYYYY or MMDDYY required. format. Enter one of the following qualifiers to identify which date is being reported: 454: Initial Treatment 304: Latest or Consultation 453: Acute Manifestation of a Chronic Condition 439: Accident 455: Last X-ray 471: Prescription
be marked. If the gender is unknown, leave this field blank. 4/1/2014 Field now reserved for NUCC use. 9c Reserved for NUCC Use Enter the name of the other insured’s employer or school. Not required 4/1/2014 Field no longer available for MassHealth use. 10d Claim Codes (Designated by NUCC) If submitting a Medicare crossover claim, enter the complete 12-character member identification (ID) number that is printed on the MassHealth card. Not required. MassHealth member identification (ID) is captured at field 1a. 4/1/2014 Changes to instructions for completing the field. 11d Is Another Health Benefit Plan? Enter an X in the appropriate box to indicate whether or not there is another health benefit plan. If Yes, complete Fields 9 and 9a through 9d. Make an entry in only one box. an X in the appropriate box to indicate whether or not there is another health benefit plan. If Yes, complete Fields 9, 9a, and 9d. Make an entry in only one box. 4/1/2014 now requires a qualifier. 14 Date of Current: Illness, Injury, or Pregnancy (LMP) Enter the start date of the present illness, injury, or condition in MMDDYYYY or MMDDYY format. For pregnancy, use the date of the last menstrual period (LMP). Enter the start date of the present illness, injury, or condition in MMDDYYYY or MMDDYY format. For pregnancy, use the date of the last menstrual period (LMP). one of the following qualifiers to indicate which date is being reported: 431: Onset of Current Symptoms of Illness 484: Last Menstrual Period 4/1/2014 Field name changed and field is now required. 15 Date Not required Enter another date related to the patient’s condition or treatment in MMDDYYYY or MMDDYY format. Enter one of the following qualifiers to identify which date is being reported: 454: Initial Treatment 304: Latest or Consultation 453: Acute Manifestation of a Chronic Condition 439: Accident 455: Last X-ray 471: Prescription