CMS 1500 Items 8-13: Patient and Insured Information

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Introduction

From electronic options to paper forms, the CMS-1500 remains a common claims format. This guide clarifies the often-confusing 8 to 13 items: patient and insured information. Whether submitting electronically or on paper, you’ll find precise instructions for accurate completion. Let’s understand how to fill CMS 1500 items 8-13.

Details of CMS 1500 Items 8-13: Patient and Insured Information

Item 8: Reserved for NUCC Use

NUCC stands for National Uniform Claim Committee. This field was previously used to report ‘Patient Status.’ Marital, employment, and student status are no longer required and have been removed from this item. Keep it blank. The NUCC will provide instructions for any use of this field.

Item 9: Other Insured’s Name

The ‘Other Insured’s Name’ indicates that there is a holder of another policy that may cover the patient. When additional group health coverage exists, enter the other insured’s full last name, first name, and middle initial of the enrollee in another health plan if it is different from that shown in Item Number 2.

If the insured uses a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name. Titles (e.g., Sister, Capt, Dr) and professional suffixes (e.g., PhD, MD, Esq) should not be included with the name. Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name. If Item Number 11d is marked, complete fields 9, 9a, and 9d, otherwise leave blank.

Item 9A: Other Insured’s Policy or Group Number

Enter the policy or group number of the other insured. Do not use a hyphen or space as a separator within the policy or group number.

Item 9B: Reserved for NUCC Use

This field was previously used to report ‘Other Insured’s Date of Birth, Sex.’ ‘Other Insured’s Date of Birth, Sex’ does not exist in 5010A1, so this field has been eliminated. Keep it blank. This field is reserved for NUCC (National Uniform Claim Committee) use. The NUCC will provide instructions for any use of this field.

Item 9C: Reserved for NUCC Use

This field was previously used to report ‘Employer’s Name or School Name.’ ‘Employer’s Name or School Name’ does not exist in 5010A1, so this field has been eliminated. Keep it blank. This field is reserved for NUCC (National Uniform Claim Committee) use. The NUCC will provide instructions for any use of this field.

Item 9D: Insurance Plan Name or Program Name

Enter the other insured’s insurance plan or program name.

This information indicates whether the patient’s illness or injury is related to employment, auto accident, or other accident. ‘Employment (current or previous)’ would indicate that the condition is related to the patient’s job or workplace. ‘Auto accident’ would indicate that the condition is the result of an automobile accident. ‘Other accident’ would indicate that the condition is the result of any other type of accident.

When appropriate, enter an X in the correct box to indicate whether one or more of the services described in Item Number 24 are for a condition or injury that occurred on the job or as a result of an automobile or other accident. Only one box on each line can be marked.
The state postal code where the accident occurred must be reported if ‘YES’ is marked in 10b for ‘Auto Accident.’ Any item marked ‘YES’ indicates there may be other applicable insurance coverage that would be primary, such as automobile liability insurance. Primary insurance information must then be shown in Item Number 11.

Item 10D: Claim Codes (Designated by NUCC)

When required by payers to provide the sub-set of Condition Codes approved by the NUCC, enter the Condition Code in this field. The Condition Codes approved for use on the 1500 Claim Form are available at www.nucc.org under Code Sets. Please refer to the most current instructions from the public or private payer regarding the need to report claim codes.

For Workers Compensation Claims: Condition Codes are required when submitting a bill that is a duplicate or an appeal. (Original Reference Number must be entered in Box 22 for these situations). Note: Do not use Condition Codes when submitting a revised or corrected bill.

Item 11: Insured’s Policy, Group, or FECA Number

The ‘Insured’s Policy, Group, or FECA Number’ is the alphanumeric identifier for the health, auto, or other insurance plan coverage. The FECA number is the 9-character alphanumeric identifier assigned to a patient claiming work-related condition(s) under the Federal Employees Compensation Act 5 USC 8101. Enter the insured’s policy or group number as it appears on the insured’s health care identification card. If Item Number 4 is completed, then this field should be completed. Do not use a hyphen or space as a separator within the policy or group number.

Item 11A: Insured’s Date of Birth, Sex

Enter the 8-digit date of birth (MM│DD│YYYY) of the insured and an X to indicate the sex (gender) of the insured. Only one box can be marked. If gender is unknown, leave it blank.

Item 11B: Other Claim ID (Designated by NUCC)

Enter the ‘Other Claim ID.’ Applicable claim identifiers are designated by the NUCC. When submitting to Property and Casualty payers, e.g., Automobile, Homeowner’s, or Workers’ Compensation insurers and related entities, the following qualifier and accompanying identifier have been designated for use:

Y4: Agency Claim Number (Property Casualty Claim Number)

Enter the qualifier to the left of the vertical, dotted line. Enter the identifier number to the right of the vertical, dotted line.

Item 11C: Insurance Plan Name or Program Name

The ‘Insurance Plan Name or Program Name’ is the name of the plan or program of the insured as indicated in Item Number 1a. Enter the name of the insurance plan or program of the insured. Some payers require an identification number of the primary insurer rather than the name in this field.

Item 11D: Is there Another Health Benefit Plan?

‘Is there another health benefit plan’ indicates that the patient has insurance coverage other than the plan indicated in Item Number 1. When appropriate, enter an X in the correct box. If marked ‘YES’, complete 9, 9a, and 9d. Only one box can be marked.

Item 12: Patient’s or Authorized Person’s Signature

Enter ‘Signature on File,’ ‘SOF,’ or legal signature. When legal signature, enter the date signed in 6-digit (MM|DD|YY) or 8-digit format (MM|DD|YYYY) format. If there is no signature on file, leave blank or enter ‘No Signature on File.’ The ‘Patient’s or Authorized Person’s Signature’ indicates there is authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim.

Item 13: Insured’s or Authorized Person’s Signature

Enter ‘Signature on File,’ ‘SOF,’ or legal signature. If there is no signature on file, leave blank or enter ‘No Signature on File.’ The ‘Insured’s or Authorized Person’s Signature’ indicates that there is a signature on file authorizing payment of medical benefits.

We hope that this article has given you a clear idea of how to fill CMS 1500 items 8-13. CMS 1500 items 8-13 contain Patient and Insured Information. The CMS-1500 form is tough to master and it’s just one piece of a big thousand-piece billing puzzle! Don’t worry, contact PrimeCare and forget about your billing worries. We are a trusted medical billing service provider for solo practitioners and small group practices. With our assistance, you can simply focus on your patients and you don’t have to worry about insurance reimbursements. We will handle it for you, ’cause that’s what we are good at. See you soon.

Reference:

Medicare Claims Processing Manual

CMS-1500 Claim Form Reference Instruction Manual

Additional CMS 1500 Resources

CMS 1500 Items 8-13: Patient and Insured Information