Commercial

Insurance

Block

1
1a
2

BCBS

x - other for ind/family plan

x - group plan
ID #

BCBS plan ID #

Pt's name LAST, FIRST, MI

Pt's DOB
MM DD YYYY
M or F (blank if unknown)

policyhldr's name, LAST, FIRST,

M

pt's mail address: street line 1,

city state line 2, zip and phone
number on line 3

x for pt's relation to

policyholder, if pt is unmarried
domestic partner, X in other
box

7
8

policyholder mailing address

and phone number
leave blank

Medicare

Medicaid

x - Medicare box

x - Medicaid box

Medicare ID #

Medicaid ID #

Leave blank only completed

if pt has other insurance
primary to Medicare

Leave blank

leave blank

Leave blank

Leave blank only completed

if pt has other insurance
primary to Medicare

Leave blank

x-

leave blank(secondary
9, 9A, 9D coverage only)
9B-9C leave blank

10A-C

10D

x - if pt's condition due to auto

accident, employment and/or
other accident. Enter state
abb. Of pt's residence for auto
accident
Leave blank. Medicaid
managed care programs,
enter E for emergency care
or U for urgency care if
instructed to do so

leave blank

11

policyholder's commercial
group # is patient is covered
by group health plan.
Otherwise leave blank

11A

policyhldr's DOB & gender. If

gender unknown, leave blank

11B

leave blank

11C

name of policyholder's
commercial health ins. Plan

policyhldr's BCBS group #

if covered by group
plan(leave blank if N/A)

name of policyhldr's BCBS

health ins. Plan

None (indicates provider

made good-faith effort to
determine if Medicare is
primary or secondary payer) Leave blank

leave blank

Leave blank

leave blank

Leave blank

11D

X - no box, only if pt does not

have secondary coverage

12

enter SOF(signature on file) leave date blank

13

enter SOF(signature on file)

14

indicate when pt 1st had

symptoms of illness, date of
injury or last menstural period
for obstetric visits. Enter as MM
DD YYYY. Enter applicable
qualifier to identify which date
is being reported: 431 (onset
of current symptoms) or 484
(last menstrual period)

leave blank

Leave blank
Leave blank

leave blank (AOB is a

provision of BCBS contracts
signed by policyholders
which authorizes BCBS to
reimburse providers
leave blank (filled in if pt has
directly
Medigap)
Leave blank

Leave blank

15-16

15. enter date as MM DD YYYY

to indicate prior episode of
same or similar illness began.
Also enter applicable qualifier
to indentify which date is being
reported. 16. enter dates as
MM DD YYYY to indicate period
of time pt was unable to work
in current job. otherwise leave
blank
leave blank

17
17A
17B

if applicable, referring
professional (FIRST, M, LAST,
Credentials) if applicable. In
front of name, enter applicable
qualifier to indentify which
provider is being preorted:
DN(referring), DK(ordering), or
DQ (supervising). Otherwise,
leave blank
leave blank
10-digit NPI of provider

18
19

admission and discharge dates

as MM DD YYYY if pt received
inpatient services, otherwise
leave blank
leave blank

15. leave blank 16. indicated

period of time pt was unable
to work in current job MM DD
YYYY
Leave blank

20

NO - all labs reported

performed in provider's office
YES - labs reported performed
in outside lab

21

enter ICD-10 codes (up to 12)

treated during encounter. ICD
indiator box: 0 for ICD-10 or 9
for ICD-9

22

leave blank(resubmitted
claims)

23

prior authorization #, referral

#, mammography
precertification # or CLIA # as
assigned by payer for service.
If n/a, leave blank

24A
24B

date procedure or service

performed in FROM as MM DD
YYYY. Enter date in TO for
procedure or service for
consecutive days during range
of dates.
POS (place of servie) code

applicable quality
improvement organization
prior authorization #,
investigational devise
exemption #, NPI for
medicaid preauthorization
physician performing care
number, assigned by
plan oversight services, 10
payer, if applicable. If
digit clinical lab improvement written preauthoization was
amendments # or skilled
obtained, attach copy to
nursing facility NPI. If n/a,
claim. Otherwise, leave
leave blank
blank

24C

leave blank

24D
24E

CPT or HCPCS level II code and

modifier (if app.) for
procedures or services
diagnosis pointer letter

24F

fee charged for each procedure

or service. If multiple
procedures reported on same
line, enter total fee charged.

24G

# of days or units for

procedures or services (if 1
procedure, enter 1)

24H
24I

leave blank (medicaid claims)

leave blank

24J
25

10-digit NPI of provider if

member of group practice,
supervising provider or
DMEPOS supplier(or leave
blank if n/a)
provider's SSN or EIN

E if service was provided

for medical emergency,
regardless of location.
Otherwise, leave blank

E if service was provided

under EPSDT program, or F
if service was provided for
family planning. B if service
categorized as both.
Otherwise, leave blank.

26

pt's account number assigned

by provider

27

YES - x if provider accepts

assignment NO - x if provider
declines assignment

28

total charges for services

and/or procedures

29-30

29. total amount patient paid

toward covered services only. If
no payment was made, leave
blank 30. leave blank
leave blank

31

provider's name and credential

and date claim was completed
as MMDDYYYY

32

name and address where

procedures or services were
provided if location is other
than provider's office or pt's
home

32A
32B
33
33A
33B

10 digit NPI of facility in block

32
leave blank
provider's billing name,
address and phone #
10 digit NPI of billing provider
or group practice
leave blank

Leave blank

Tricare

Worker's Comp

x - FECA box if claim is

submitted to Division of
Federal Employees'
Compensation (DFEC).
Otherwise, enter x in other
X - TRICARE/CHAMPUS box box
Sponsor's SSN as it appears
on the CAC card
Pt's SSN

Sponsor's name, LAST,

FIRST, MI

Pt's employer

x - other box

employer's mailing address

and telephone number

A: X - yes box B-C: X in

appropriate boxes in indicate
it pt's condition is related to
car accident and/or other
accident. Enter state abb. For
auto accident of pt's
residence

If DD Form 2527 is
attached, enter DD FORM
2527 ATTACHED, otherwise
leave blank

Leave blank

enter nine-digit FECA #

Leave blank

leave blank
enter claim # assigned by
workers' compensation third
party payer

Leave blank

enter name of workers'

compensation payer

leave blank
leave blank

leave blank

if applicable, enter the

preauthorization number.
Otherwise, leave blank

enter any preauthorization #

assigned by the workers'
compensation payer.
Otherwise, leave blank.

Leave blank

leave blank