Billing instuction box 11D – 16 – Is there another health benefit plan
Billing instruction for Ambulance Billing – Box 11d to 16
| BlockNo. | Block Name | Block Code | Notes |
| 11d | Is There Another Health Benefit Plan? | A | If the patient has another resource available to pay for the service, bill the other resource before billing MA. If the YES box is checked, Blocks 9a-d must be completed with the information on the additional resource. |
| 12 | Patient’s or Authorized Person’s Signature and Date | M/M | The recipient’s signature or the words Signature Exception must appear in this field. Also, enter the date of claim submission in an 8- digit MMDDCCYY format (e.g., 03012004) with no slashes, hyphens, or dashes.) Note: Please refer to Section 6 of the PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form for additional information on obtaining patients signatures. |
| 13 | Insured’s or Authorized Person’s Signature | O | If completed, this block should contain the signature of the insured, if the insured is not the patient. |
| 14 | Date of Current: | O | If completed, enter the date of the current illness (first symptom), injury (accident date), or pregnancy in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012004). |
| 15 | If Patient Has Had Same or Similar Illness | O | If the patient has had the same or similar illness, list the date of the first onset of the illness in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012002). |
| 16 | Dates Patient Unable to Work in Current Occupation | O | If completed, enter the FROM and TO dates in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012003), only if the patient is unable to work due to the current illness or injury. This block is only necessary for Worker’s Compensation cases. It must be left blank for all other situations. |
Billing instruction for Ambulance Billing – Box 11d to 16
| BlockNo. | Block Name | Block Code | Notes |
| 11d | Is There Another Health Benefit Plan? | A | If the patient has another resource available to pay for the service, bill the other resource before billing MA. If the YES box is checked, Blocks 9a-d must be completed with the information on the additional resource. |
| 12 | Patient’s or Authorized Person’s Signature and Date | M/M | The recipient’s signature or the words Signature Exception must appear in this field. Also, enter the date of claim submission in an 8- digit MMDDCCYY format (e.g., 03012004) with no slashes, hyphens, or dashes.) Note: Please refer to Section 6 of the PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form for additional information on obtaining patients signatures. |
| 13 | Insured’s or Authorized Person’s Signature | O | If completed, this block should contain the signature of the insured, if the insured is not the patient. |
| 14 | Date of Current: | O | If completed, enter the date of the current illness (first symptom), injury (accident date), or pregnancy in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012004). |
| 15 | If Patient Has Had Same or Similar Illness | O | If the patient has had the same or similar illness, list the date of the first onset of the illness in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012002). |
| 16 | Dates Patient Unable to Work in Current Occupation | O | If completed, enter the FROM and TO dates in an eight-digit MMDDCCYY (month, day, century, and year) format (e.g., 03012003), only if the patient is unable to work due to the current illness or injury. This block is only necessary for Worker’s Compensation cases. It must be left blank for all other situations. |