Block 6 PATIENT’S RELATIONSHIP TO INSURED Enter the appropriate – relationship only when there is third party health insurance besides Medicare and Medicaid. Optional. – 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. Optional. – Block 8 PATIENT STATUS No entry required. – Block 9 OTHER INSURED’S NAME No entry required. – Block 9a OTHER INSURED’S POLICY OR GROUP NUMBER Enter the patient’s – (recipient’s) 11-digit Maryland Medical Assistance number exactly as it appears on the MA card. The MA number must appear in this Block regardless of whether or not a recipient has other insurance. Medical Assistance eligibility should be verified on each date of service by calling EVS. EVS is operational 24 hours a day, 365 days a year at the following number: 1-866-710-1447- Required Block 9b OTHER INSURED’S DATE OF BIRTH No entry required. – Block 9c EMPLOYER’S NAME OR SCHOOL NAME No entry required. – 9d INSURANCE PLAN OR PROGRAM NAME Enter the insured’s group name – and group number only when there is third party health insurance coverage besides Medicare and Medicaid. Optional. – IS PATIENT’S CONDITION RELATED TO - Check or to 10a “Yes” “No” thru 10c 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. Optional. – Block 10d RESERVED FOR LOCAL USE When billing for abortions or abortion – related service, enter the appropriate two-alpha character (AA-AH) condition code from the table below. This field should ONLY BE USED for abortions and abortion related services, otherwise leave blank. Abortion Performed due to Rape Code indicates abortion performed due to AA(a) a rape. Abortion Performed due to Incest Code indicates abortion performed due to AB(a) an incident of incest. Abortion Performed due to Code indicates abortion performed due to AC(a) Serious Fetal Genetic Defect, a genetic defect, a deformity, or Deformity, or abnormality to the fetus. Abnormality
Block 6 PATIENT’S RELATIONSHIP TO INSURED – Enter the appropriate relationship only when there is third party health insurance besides Medicare and Medicaid. – Optional. 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. – Optional. Block 8 PATIENT STATUS – No entry required. Block 9 OTHER INSURED’S NAME – No entry required. Block 9a OTHER INSURED’S POLICY OR GROUP NUMBER – Enter the patient’s (recipient’s) 11-digit Maryland Medical Assistance number exactly as it appears on the MA card. The MA number must appear in this Block regardless of whether or not a recipient has other insurance. Medical Assistance eligibility should be verified on each date of service by calling EVS. EVS is operational 24 hours a day, 365 days a year at the following number: 1-866-710-1447- Required Block 9b OTHER INSURED’S DATE OF BIRTH – No entry required. Block 9c EMPLOYER’S NAME OR SCHOOL NAME – No entry required. 9d INSURANCE PLAN OR PROGRAM NAME – Enter the insured’s group name and group number only when there is third party health insurance coverage besides Medicare and Medicaid. – Optional. 10a IS PATIENT’S CONDITION RELATED TO - Check “Yes” or “No” to thru 10c 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. – Optional. Block 10d RESERVED FOR LOCAL USE – When billing for abortions or abortion related service, enter the appropriate two-alpha character (AA-AH) condition code from the table below. This field should ONLY BE USED for abortions and abortion related services, otherwise leave blank. AA(a) Abortion Performed due to Rape Code indicates abortion performed due to a rape. AB(a) Abortion Performed due to Incest Code indicates abortion performed due to an incident of incest. AC(a) Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality Code indicates abortion performed due to a genetic defect, a deformity, or abnormality to the fetus.
CMS1500%20Billing%20Instructions.docx