Understanding and accurately completing Box 11 on the CMS-1500 claim form is critical for efficient medical billing. Often referred to historically as the HCFA-1500 form, the CMS-1500 is the standard form used by non-institutional providers and suppliers to bill Medicare for services. Specifically, Box 11 requires the Insured’s Policy or Group Number, a key detail that significantly impacts how a medical claim is processed, especially concerning Medicare’s primary or secondary payer status. This field is always a required field for paper claims, and its accurate completion helps prevent claim delays.

For those searching for details on “in medical claim cms 1500 form box 11” or “box 11 on cms 1500 paper format,” this guide provides comprehensive instructions. When filling out the “groupnumber in cms 1500 form” section, understanding its nuances is essential.

As stated in the official CMS-1500 claim form instructions:

“This item must be completed. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to items 11A-11C.

NOTE: Enter the appropriate information in Item 11C if insurance primary to Medicare is indicated in Item 11. If there is no insurance primary to Medicare, enter the word “NONE” and proceed to Item 12.”

Understanding Medicare Primary/Secondary Payer Rules

The “good faith effort” mentioned in the CMS instructions underscores the provider’s responsibility to determine the correct payer order before submitting a claim. Incorrectly identifying Medicare as primary when another payer is responsible can lead to claim denials and delays. Medicare can be a secondary payer in various situations, often when beneficiaries have other forms of health coverage. Here are common scenarios:

• Working Aged Beneficiaries: If a Medicare beneficiary or their spouse is still working and covered by a group health plan (GHP) from an employer with 20 or more employees, the GHP is generally primary, and Medicare is secondary.
• End-Stage Renal Disease (ESRD): For beneficiaries with ESRD, if they are within the 30-month coordination period, a GHP may be primary during this time, with Medicare as the secondary payer.
• Disability: For disabled beneficiaries under 65, if they are covered by a GHP due to their own or a family member’s current employment, the GHP may be primary if the employer has 100 or more employees.
• Other Insurance: This includes situations with Black Lung benefits, Workers’ Compensation, no-fault insurance, or liability insurance. In these cases, those payers are typically primary.

What to Enter in Box 11: Examples

Box 11 is designed to capture the insured’s policy or group number from their primary insurance carrier if that carrier is *not* Medicare. It is crucial to understand that specific “codes” are not entered directly into Box 11; rather, it’s the policy or group identifier. Any related codes, such as payer type codes, would typically be found in adjacent or related fields.

Here are simplified examples for how Box 11 would be completed:

• Scenario 1: Medicare is secondary to a Commercial Health Plan.
  A patient has commercial insurance through their employer (e.g., Blue Cross Blue Shield) and is also eligible for Medicare. The commercial plan is determined to be primary.

  Box 11 Entry: Enter the patient’s Policy/Group Number from their Blue Cross Blue Shield plan (e.g., “BCBS123456789”).

• Scenario 2: Medicare is the primary payer.
  A patient only has Medicare, or Medicare has been determined to be primary (e.g., they are retired and have no other primary coverage).

  Box 11 Entry: Enter the word “NONE”.

What Information is Required with Box 11 Completion?

When Box 11 contains a policy or group number, indicating there is insurance primary to Medicare, several other items on the CMS-1500 form become mandatory to ensure accurate processing:

• Item 4 – Insured’s Name
• Item 6 – Patient Relationship to Insured
• Item 7 – Insured’s Address
• Item 11C – Insurance Plan Name or Program Name

Enhancing EOB Requirements & Avoiding Common Claim Processing Delays

A crucial component for secondary Medicare claims when primary insurance exists is the Explanation of Benefits (EOB) from the primary payer. A copy of the primary payer’s EOB MUST be attached to the claim.

To avoid delays and ensure proper reimbursement, the EOB must contain specific information that precisely matches the Medicare claim. Emphasize the following critical matching criteria:

• Physician/Supplier Identification: The EOB should reflect the same physician or supplier’s name or code as listed on the Medicare claim.
• Dates of Service: The dates of service for the period over which the services were rendered on the EOB must precisely match those on the Medicare claim.
• Actual Charges: The actual charges for the services on the EOB must be identical to the charges submitted on the Medicare claim.
• Primary Paid and Allowed Amounts: The EOB must clearly state the primary paid and primary allowed amounts for the corresponding services billed.

Furthermore, when an EOB is attached, the following information MUST also be submitted on the CMS-1500 form to ensure a complete submission:

• Item 4 – Insured’s Name
• Item 6 – Patient Relationship to Insured
• Item 7 – Insured’s Address
• Item 11 – Policy Number
• Item 11C – Insurance Plan Name or Program Name

Failure to adhere to these guidelines can lead to significant delays in processing claims. Common situations that cause processing delays include:

• If Item 11 contains a policy number, but the corresponding EOB is not attached.
• If the patient’s EOB is attached, but Item 11 is blank or incorrectly states “NONE” when primary insurance exists.
• If Item 11 is left entirely blank when a policy number or “NONE” is required.