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On the HCFA-1500 form, box 3 is designated for the patient's birth date and sex. This is the patient who the services were rendered to for the claim. Check the box for the patient's sex and enter the patient's birth date using the complete 4-digit year.
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On the HCFA-1500 form, box 2 is designated for the patient's name (Last, First, Middle). This is the patient who the services were rendered to for the claim. The name should be entered exactly as it appears on the patient's member card.
On the HCFA-1500 form, box 1a is designated for the insured's ID Number. This will normally be the insured id number for the subscriber of the claim.
On the HCFA-1500 form, box 1 is designated for the type of health insurance of the claim. There are seven types of plans to choose from. Medicare, Medicaid, Tricare, ChampVA, Group Health Plan, FECA BLK Lung, Other.
The space at the top area of the HCFA-1500 form, known as the carrier block, is typically reserved for the payer information of the claim. The primary payer of the subscriber should go here, which will contain the destination information of where the claim should be routed to for processing.
The 2310D REF Supervising Provider Secondary Identification Segment is required when a secondary number is necessary to identify the provider. The 5010 specifications for the REF segment can be found below as it pertains to the 2310D loop.
