Block 4 Enter name (Last Name, First Name, and – INSURED’S NAME – Middle Initial) If the patient has other third party insurance, enter the name of – the person in whose name the third party coverage is listed (No entry required when billing for a patient without third-party insurance). Block 5 Enter the complete mailing address –PATIENT’S ADDRESS – patient’s with zip code and telephone number (Optional). Block 6 RELATIONSHIP TO INSURED Enter the – PATIENT’S – appropriate relationship only when there is third party health insurance besides Medicare and Medicaid (No entry required when billing for a patient without third-party insurance). Block 7 ADDRESS When there is third party health insurance – INSURED’S – coverage besides Medicare and Medicaid, enter the address and insured’s telephone number (No entry required when billing for a patient without insurance). Block 8 RESERVED FOR NUCC USE. – Block 9 OTHER NAME No entry required. – INSURED’S – Block 9a OTHER POLICY OR GROUP NUMBER Enter – INSURED’S – the patient's exactly as it eleven digit Maryland medical assistance number appears on the Medical Assistance card. Check for transposition of numbers. The MA number must appear here regardless of whether or not a patient has other insurance. A patient's Medicaid eligibility should be verified on date of each service, to rendering service, by calling the EVS. EVS is operational 24 prior hours a day, 365 days a year at the following number: 1-866-710-1447 or online at. Block 9b RESERVED FOR NUCC USE No entry required. – – Block 9c RESERVED FOR NUCC USE No entry required. – – Block 9d INSURANCE PLAN OR PROGRAM NAME Enter the insured's – – group name and group number if the patient has health insurance besides Medicare/Medicaid (No entry required when billing for a patient without insurance).
Block 4 – INSURED’S NAME – Enter name (Last Name, First Name, and Middle Initial) – If the patient has other third party insurance, enter the name of the person in whose name the third party coverage is listed (No entry required when billing for a patient without third-party insurance). Block 5 –PATIENT’S ADDRESS – Enter the patient’s complete mailing address with zip code and telephone number (Optional). Block 6 – PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party health insurance besides Medicare and Medicaid (No entry required when billing for a patient without third-party insurance). Block 7 – INSURED’S ADDRESS – When there is third party health insurance coverage besides Medicare and Medicaid, enter the insured’s address and telephone number (No entry required when billing for a patient without insurance). Block 8 – RESERVED FOR NUCC USE. Block 9 – OTHER INSURED’S NAME – No entry required. Block 9a – OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the patient's eleven digit Maryland medical assistance number exactly as it appears on the Medical Assistance card. Check for transposition of numbers. The MA number must appear here regardless of whether or not a patient has other insurance. A patient's Medicaid eligibility should be verified on each date of service, prior to rendering service, by calling the EVS. EVS is operational 24 hours a day, 365 days a year at the following number: 1-866-710-1447 or online at. Block 9b – RESERVED FOR NUCC USE – No entry required. Block 9c – RESERVED FOR NUCC USE – No entry required. Block 9d – INSURANCE PLAN OR PROGRAM NAME – Enter the insured's group name and group number if the patient has health insurance besides Medicare/Medicaid (No entry required when billing for a patient without insurance).
I.%20CMS-1500%20Billing%20Instructions.docx