STATE ZIP CODE TELEPHONE (Include Area Code) 8. RESERVED Reserved for NUCC use. If patient has other insurance coverage as indicated 9. OTHER INSURED’S NAME in Field 11d, the other insured’s last name, first name, (Last name, First Name, and middle initial. Middle Initial) a. OTHER INSURED’S Policy and/or group number of the insured individual. POLICY OR GROUP NUMBER b. RESERVED Reserved for NUCC use. SEX Not required. c. RESERVED Reserved for NUCC use. d. INSURANCE PLAN Name of the insurance company. NAME OR PROGRAM NAME 10. IS PATIENT’S CONDITION RELATED TO: a. EMPLOYMENT? (Current Check YES or NO. or Previous) b. AUTO ACCIDENT? Required when an auto accident is related to the services. Check YES or NO. (State) If 10b is YES, the two-letter postal abbreviation for the in which the automobile accident took place. c. OTHER ACCIDENT? Required when an accident other than automobile is related to the services. Check YES or NO. d. CLAIM CODES The Codes” identify additional information “Claim about the beneficiary’s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at under Code Sets. 11. INSURED’S POLICY GROUP Not required when Medicaid is the only payer. OR FECA NUMBER a. INSURED’S DATE OF Not required. BIRTH SEX Not required. b. OTHER CLAIM ID Not required. NUMBER c. INSURANCE PLAN Not required. NAME OR PROGRAM NAME
STATE ZIP CODE TELEPHONE (Include Area Code) 8. RESERVED Reserved for NUCC use. 9. OTHER INSURED’S NAME (Last name, First Name, Middle Initial) If patient has other insurance coverage as indicated in Field 11d, the other insured’s last name, first name, and middle initial. a. OTHER INSURED’S POLICY OR GROUP NUMBER Policy and/or group number of the insured individual. b. RESERVED Reserved for NUCC use. SEX Not required. c. RESERVED Reserved for NUCC use. d. INSURANCE PLAN NAME OR PROGRAM NAME Name of the insurance company. 10. IS PATIENT’S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) Check YES or NO. b. AUTO ACCIDENT? Required when an auto accident is related to the services. Check YES or NO. (State) If 10b is YES, the two-letter postal abbreviation for the in which the automobile accident took place. c. OTHER ACCIDENT? Required when an accident other than automobile is related to the services. Check YES or NO. d. CLAIM CODES The “Claim Codes” identify additional information about the beneficiary’s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at under Code Sets. 11. INSURED’S POLICY GROUP OR FECA NUMBER Not required when Medicaid is the only payer. a. INSURED’S DATE OF BIRTH Not required. SEX Not required. b. OTHER CLAIM ID NUMBER Not required. c. INSURANCE PLAN NAME OR PROGRAM NAME Not required.
EIDT_II.docx