Medicare Information Resource - Part B Supplement, 2006-9B: CMS-1500 Claim Form

Page Tool

Printable View

Content Section

Medicare News Brief Medicare Information Resource

MIR-2006-9B, September 2006

CMS-1500 Claim Form – Item 11 Reminder

Effective October 1, 2006 :

Any CMS-1500 claim form received with incomplete or missing information in Items 11, 11A, 11B, and 11C will be returned as unprocessable.

Item 11 is a required field on the CMS-1500 claim form. For your information, we have included instructions for completing these items below.

If there is NO insurance primary to Medicare, report the word “NONE” as indicated in the instructions for Item 11. The only acceptable verbiage in Item 11 is “None” or the policy number of the insured. Entering any other information in this field will cause the claim to be unprocessable.

You can obtain complete CMS-1500 claim form instructions at: http://www.empiremedicare.com/partbny/1500/instructions.htm

Item 11

11. INSURED’S POLICY GROUP OR FECA NUMBER

Medicare requires completion of this Item.

This Item must be completed. By completing this Item, the provider acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer.

Medicare is primary:	If there is no insurance primary to Medicare, enter the word “NONE” and proceed to Item 12.
Medicare is Secondary:	If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Items 11a through 11c. When completing Items 11a – 11c also complete Items 4, 6, and 7.

Note:
For a CMS-1500 paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payers explanation of benefits (EOB) notice must be forwarded along with the claim form.

Enter the word “NONE,” if the insured reports a terminating event with regard to insurance, which had been primary to Medicare (e.g., insured retired) and proceed to Item 11b.

Medicare Secondary Payer (MSP) Claims submitted by a Laboratory:

If a lab has collected previously and retained MSP information for a beneficiary, the lab may use that information for billing purposes of the non-face-to-face lab service.

If the lab has no MSP information for the beneficiary, the lab will enter the word “None” in Item 11 of Form CMS-1500, when submitting a claim for payment of a reference lab service. Where there has been no face-to-face encounter with the beneficiary, the claim will then follow the normal claims process. When a lab has a face-to-face encounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.

Circumstances under which Medicare payment may be secondary to other insurance include patients covered by:

Group Health Plan Coverage:

Working Aged; Disability (large group health plan);
End Stage Renal Disease (ESRD);

No fault and/or other liability
Work-related illness/injury:

Workers’ Compensation; Black Lung;
Veterans benefits

Item 11a

a. INSURED’S DATE OF BIRTH

SEX

M F

Enter the insured’s 8-digit birth date (MM DD CCYY) and sex, if different from Item 3.

Item 11b

b. EMPLOYER’S NAME OR SCHOOL NAME

Enter the employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the 8-digit retirement date (MM DD CCYY) preceded by the word “Retired.”

Item 11c

c. INSURANCE PLAN NAME OR PROGRAM NAME

Enter the complete insurance plan name. If the primary payer’s Explanation of Benefits (EOB) does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in Item 11.

Item 11d

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES NO If yes, return to and complete Item 9 a-d.

Leave blank. Not required by Medicare.