how to fill ambulance claim – CMS 1500 – BOX 5 – BOX 9B
Billing instruction for Ambulance Billing
| BlockNo. | Block Name | Block Code | Notes |
| 5 | Patient’s Address | O | Enter the patient’s address. |
| 6 | Patient’s Relationship to the Insured | A | Check the appropriate box for the patient’s relationship to the insured listed in Block 4. |
| 7 | Insured’s Address | A | Enter the insured’s address and telephone number except when the address is the same as the patient’s, then enter the word SAME. Complete this block only when Block 4 is completed. |
| 8 | Patient Status | O | Place an X in the appropriate blocks to describe the patient’s status. |
| 9 | Other Insured’s Name | A | If the patient has another health insurance secondary to the insurance named in Block 11, enter the last name, first name, and middle initial of the insured if it is different from the patient named in Block 2. If the patient and the insured are the same, enter the word SAME. If the patient has MA coverage only, leave the block blank. |
| 9a | Other Insured’s Policy and Group Number | A | This block identifies a secondary insurance other than MA, and the primary insurance listed in 11a- d. Enter the policy number and the group number of any secondary insurance that is available. Only use Blocks 9a-d, if you have completed Blocks 11a-d, and a secondary policy is available. (For example, the patient may have both Blue Cross and Aetna benefits available.) |
| 9b | Other Insured’s Date of Birth and Sex | A | If a secondary insurance exists, enter the other insured’s date of birth. Please make sure the date is in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and indicate the patient’s gender by placing an X in the appropriate box. |
Billing instruction for Ambulance Billing
| BlockNo. | Block Name | Block Code | Notes |
| 5 | Patient’s Address | O | Enter the patient’s address. |
| 6 | Patient’s Relationship to the Insured | A | Check the appropriate box for the patient’s relationship to the insured listed in Block 4. |
| 7 | Insured’s Address | A | Enter the insured’s address and telephone number except when the address is the same as the patient’s, then enter the word SAME. Complete this block only when Block 4 is completed. |
| 8 | Patient Status | O | Place an X in the appropriate blocks to describe the patient’s status. |
| 9 | Other Insured’s Name | A | If the patient has another health insurance secondary to the insurance named in Block 11, enter the last name, first name, and middle initial of the insured if it is different from the patient named in Block 2. If the patient and the insured are the same, enter the word SAME. If the patient has MA coverage only, leave the block blank. |
| 9a | Other Insured’s Policy and Group Number | A | This block identifies a secondary insurance other than MA, and the primary insurance listed in 11a- d. Enter the policy number and the group number of any secondary insurance that is available. Only use Blocks 9a-d, if you have completed Blocks 11a-d, and a secondary policy is available. (For example, the patient may have both Blue Cross and Aetna benefits available.) |
| 9b | Other Insured’s Date of Birth and Sex | A | If a secondary insurance exists, enter the other insured’s date of birth. Please make sure the date is in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03011978) and indicate the patient’s gender by placing an X in the appropriate box. |