If the patient was referred to you by another provider, then enter the providers information here. You will need the providers NPI. You can search for a providers NPI at the NPI registry.
Some insurance require a referring provider for certain services. You may need to ask the insurance company if they will require the referring provider.
An example might be if you are a physical therapist, you may need to enter the ordering provider.
If the patients condition kept them from working, you can indicate here the dates that the patient was unable to work. If the patient is still unable to work at the time you are creating the claim, then you can leave the “to date” blank.
You can leave this field blank if it does not pertain to your service.
In Therabill, you can enter this date under the Advanced Info when entering or editing a patient / client.
Indicates whether the patient has ever had a similar (or the same) illness in the past. If they have, then enter the date in box 15. You can usually leave this box blank. In Therabill, you can enter this date using the Advanced form on the client / patient input form.
This is where you give the date that the current illness, injury, or pregnancy occurred. Having a date in Box 14 is not required for all claims. If it doesn’t fit your claim, you can leave Box 14 blank.
For pregnancy related claims, enter the date of the last menstrual period.
For accident related claims, enter the accident date here.
This is where the insured (the person who has the insurance) signs to authorize payment of medical benefits to be sent to the billing provider.
As with Box 12, you can indicate that the signature is on file. If you are using Therabill to create your claims, Therabill will automatically put “On File” into Box 33.
NOTE: Have a signature in Box 13 does not always guarantee that the insurance company will send payment to the billing provider. Each insurance company has their own set of rules.
This is where the patients signature would go to authorize release of medical information necessary to process the claim. If you are manually filling out the CMS form, you can ask the patient to sign the form, or you can indicate that you have the patients signature on file.
If you use Therabill, the Box 12 will be automatically entered as “On File” and the date will be entered as the date that you created the claim.
This is where you indicate if the patient has another insurance carrier. Mark “yes” by putting in X in the yes box if the patient does have another insurance carrier. If you indicate “yes” then you will need to fill out boxes 9 – 9d.
The name of the insurance plan or program that you are billing.
The insured’s employer name or school name if the insurance plan is thru an employer or thru a school.
The insureds date of birth and gender. The date of birth should be entered in the format MM/DD/YYYY and put a check in the appropriate checkbox to indicate the gender of the insured.
Some insurance companies will require the insured’s date of birth and may reject electronic claims without it.
