5 ADDRESS Enter the patient’s complete mailing address with –PATIENT’S – zip code and telephone number (Optional). 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 third-party insurance). 8 RESERVED FOR NUCC USE. – Block 9 OTHER INSURED’S NAME No entry required. – – 9a OTHER INSURED’S POLICY OR GROUP NUMBER Enter the – – patient's exactly as it appears on the eleven digit Maryland medical assistance number 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 service, to rendering service, each prior 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 third-party insurance). Block 10a thru 10c (Block 10d only for abortion-related billing) IS PATIENT’S – CONDITION RELATED TO Check "Yes" or "No" to indicate whether employment, – auto liability or other accident involvement applies to one or more of the services described in Item 24, if this information is known. If not known, leave blank. Block 11 INSURED’S POLICY GROUP OR FECA NUMBER If the patient has – – other third-party insurance and the claim has been rejected by that insurance, enter For information regarding participant’s the appropriate rejection code listed below: coverage, contact Third Party Liability Unit at 410-767-1765 . Code Rejection Reasons
5 –PATIENT’S ADDRESS – Enter the patient’s complete mailing address with zip code and telephone number (Optional). 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 third-party insurance). 8 – RESERVED FOR NUCC USE. Block 9 – OTHER INSURED’S NAME – No entry required. 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 third-party insurance). Block 10a thru 10c (Block 10d only for abortion-related billing) – IS PATIENT’S CONDITION RELATED TO – Check "Yes" or "No" to indicate whether employment, auto liability or other accident involvement applies to one or more of the services described in Item 24, if this information is known. If not known, leave blank. Block 11 – INSURED’S POLICY GROUP OR FECA NUMBER – If the patient has other third-party insurance and the claim has been rejected by that insurance, enter the appropriate rejection code listed below: For information regarding participant’s coverage, contact Third Party Liability Unit at 410-767-1765 . Code Rejection Reasons
Section_6_2017.docx