Item Descriptions

Question 1

Item 1

Answer 1

Type of primary insurance: either Medicare or Other

Question 2

Item 1a

Answer 2

Insurance ID

Question 3

Item 2

Answer 3

Patient’s last name, first name, and middle initial if any as shown on patient’s insurance card.

Question 4

Item 3

Answer 4

8 digit birthday and sex

Question 5

Item 4

Answer 5

Name of insured or SAME. If Medicare is primary, leave blank.

Question 6

Item 5

Answer 6

Mailing address & phone number

Question 7

Item 6

Answer 7

Patient’s relationship if item 4 is completed

Question 8

Item 7

Answer 8

Insured’ address or SAME. Use only if items 4, 6, and 11 are completed.

Question 9

Item 8

Answer 9

Eliminated field

Question 10

Item 9

Answer 10

Full name of Medigap policy enrollee or SAME.

If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

Only participating providers complete this field.

Question 11

Other supplemental coverage for Item 9

Answer 11

Not listed. Auto forwarded by Medicare or beneficiary files his/her own claim.

Question 12

Item 9a

Answer 12

Medigap policy and/or group number preceded by either of the following:

MEDIGAP
MG
MGAP

Question 13

Item 9b

Answer 13

Eliminated field reserved for use by the NUCC (National Uniform Claim Committee)

Question 14

Item 9c

Answer 14

Eliminated field reserved for use by the NUCC (National Uniform Claim Committee)

Question 15

Item 9d

Answer 15

The other insured’ plan or program name

Question 16

Items 10a through 10c

Answer 16

Yes or No questions to relationship to patient’s condition:

Employment
Auto Accident (requires state)
Other Accident

Question 17

Item 10d

Answer 17

Used when payers require a sub-set of NUCC condition codes

Question 18

Item 11

Answer 18

The insured’ policy, group, or FECA (Federal Employee Compensation Act) number. The FECA is a 9 digit number.

Question 19

Item 11a

Answer 19

Insured’ 8 digit birthday and sex

Question 20

Item 11b

Answer 20

Employer’s name or school name

Question 21

Item 11c

Answer 21

Insurance plan name or school name

Question 22

Item 11d

Answer 22

Yes or no question to if any other health coverage exists. If so, this is when Item 9 and it’s subsections would be filled in if not previously used for Medigap.

Question 23

Item 12

Answer 23

Patient or authorized signature and date

Can state signature on file or can be a computer generated signature

Question 24

Item 13

Answer 24

Insured’s or other authorized person’s signature and date

Can state signature on file or can be a computer generated signature

If payment can only be made on an assignment related basis or physician/supplier is considered participating, no signature is required.

Question 25

Item 14

Answer 25

Illness, injury, or LMP date

Question 26

Item 14

Answer 26

Any other date related to patient's condition

Question 27

Item 16

Answer 27

Date patient is unable to work if applicable. Ex. EDC

Question 28

Item 17

Answer 28

Name of referring/ordering physician

Question 29

Item 17a

Answer 29

CMS NPI of referring/ordering physician

Question 30

Item 17b

Answer 30

NPI of referring/ordering physician

Question 31

Item 18

Answer 31

Hospitalization dates related to current services

Question 32

Item 19

Answer 32

For additional claim information. The following qualifiers can be used on the 5010A1: ``` 0B State License Number 1G Provider UPIN Number G2 Provider Commercial Number LU Location Number (For supervising Provider only) N5 Provider Plan Network ID Number SY SSN X5 State Industrial Accident Provider Number ZX Provider Taxonomy (PXC for 5010A1) ``` If a 2nd item needs reported, enter 3 spaces and then add the next qualifier and information.