BOX 9C to 11C – Is patient condition related to field of CMS 1500
Billing instruction for Ambulance Billing – Box 9C to 11C
| BlockNo. | Block Name | Block Code | Notes |
| 9c | Employer’s Name or School Name | A | Enter the name of the other insured’s employer. |
| 9d | Insurance Plan Name or Group Name | A | Enter the other insured’s insurance plan name or group name. |
| 10a-10c | Is Patient’s Condition Related To: | A | Complete the block by placing an X in the appropriate YES or NO box to indicate whether the patient’s condition is related to employment, auto accident, or other accident (e.g., liability suit) as it applies to one or more of the services described in Block 24d. For auto accidents, enter the state’s 2-digit postal code for the state in which the accident occurred in the PLACE block (e.g., PA for Pennsylvania). |
| 10d | Reserved For Local Use | O | It is optional to enter the 9-digit social security number of the policyholder if the policyholder is not the recipient. |
| 11 | Insured’s Policy Group or FECA Number | A/A | Enter the policy number and group number of the primary insurance other than MA. |
| 11a | Insured’s Date of Birth and Sex | A/A | Enter the insured’s date of birth in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and insured’s gender if it is different than Block 3. |
| 11b | Employer’s Name or School Name | A | Enter the name of the other insured’s employer for the primary insurance. |
| 11c | Insurance Plan Name or Program Name | A | List the name and address of the primary insurance listed in Block 11. |
Billing instruction for Ambulance Billing – Box 9C to 11C
| BlockNo. | Block Name | Block Code | Notes |
| 9c | Employer’s Name or School Name | A | Enter the name of the other insured’s employer. |
| 9d | Insurance Plan Name or Group Name | A | Enter the other insured’s insurance plan name or group name. |
| 10a-10c | Is Patient’s Condition Related To: | A | Complete the block by placing an X in the appropriate YES or NO box to indicate whether the patient’s condition is related to employment, auto accident, or other accident (e.g., liability suit) as it applies to one or more of the services described in Block 24d. For auto accidents, enter the state’s 2-digit postal code for the state in which the accident occurred in the PLACE block (e.g., PA for Pennsylvania). |
| 10d | Reserved For Local Use | O | It is optional to enter the 9-digit social security number of the policyholder if the policyholder is not the recipient. |
| 11 | Insured’s Policy Group or FECA Number | A/A | Enter the policy number and group number of the primary insurance other than MA. |
| 11a | Insured’s Date of Birth and Sex | A/A | Enter the insured’s date of birth in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and insured’s gender if it is different than Block 3. |
| 11b | Employer’s Name or School Name | A | Enter the name of the other insured’s employer for the primary insurance. |
| 11c | Insurance Plan Name or Program Name | A | List the name and address of the primary insurance listed in Block 11. |