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HCFA 1500 - Physicians and Non-Institutional Providers

Data Elements that are necessary, if applicable

(unless otherwise agreed to by contract)

Field # Data Element
9 Other insured´s or enrollee´s name - applicable if Field 11d is answered "yes"*
9a Other insured´s or enrollee´s policy/group number - applicable if Field 11d is answered "yes"*
9b Other insured´s or enrollee´s date of birth - applicable if Field 11d is answered "yes"*
9c Other insured´s or enrollee´s plan name (employer, school, etc) - applicable if Field 11d is answered "yes"*
9d Other insured´s or enrollee´s HMO or insurer name - applicable if Field 11d is answered "yes"*
11b Subscriber´s plan name (employer, school, etc.) - applicable if health plan is a group plan
23 Prior authorization number - applicable when prior authorization is required
27 Whether assignment was accepted - applicable when assignment under Medicare has been accepted
29 Amount paid - applicable if an amount has been paid by or on behalf of the patient or subscriber or by a primary plan
30 Balance due - applicable if an amount has been paid by or on behalf of the patient or subscriber

* If answer in field 11d is "Yes", then the data elements in fields 9, 9a, 9b, 9c, and 9d must be completed unless the physician or provider submits proof of a good faith but unsuccessful effort to obtain this information from the enrollee/insured.


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Last updated: 11/20/2009



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Translation by WorldLingo


Translation by WorldLingo