Essential Data Elements for a HCFA1500

 

Data Elements that are required:

Field # Data Element
1a Subscriber´s or patient´s plan ID number
2 Patient´s name
3 Patient´s date of birth and gender
4 Subscriber´s name
5 Patient´s address (street or post office box, city, zip)
6 Patient´s relationship to subscriber
7 Subscriber´s address
10 Whether patient´s condition is related to employment, auto accident, or other accident
11 Subscriber´s policy number
11a Subscriber´s birth date and gender
11c HMO or preferred provider carrier name
11d Disclosure of any other health benefit plans*
12 Patient´s or authorized person´s signature or notation that the signature is on file with the physician or provider
13 Subscriber´s or authorized person´s signature or notation that the signature is on file with the physician or provider
14 Date of current illness, injury or pregnancy
15 First date of previous, same or similar illness
21 Diagnosis codes or nature of illness or injury
24A Date(s) of service
24B Place of service codes
24C Type of service code
24D Procedure/modifier code
24E Diagnosis code by specific service
24F Charge for each listed service
24G Number of days or units
25 Physician´s or provider´s federal tax ID number
28 Total Charge
31 Signature of physician or provider or notation that the signature is on file with the HMO or preferred provider carrier
32 Name and address of facility where services were rendered (if other than home or office)
33 Physician´s or provider´s billing name and address

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then data elements in fields 9, 9a, 9b, 9c, and 9d must be completed. If answer is “No”, then fields 9, 9a, 9b, 9c, and 9d are not essential data elements if the physician or provider has on file a statement signed by the patient/insured within the last 12 months that there is no other coverage. Such statement may be in the form of initial or annual office visit questionnaires, patient sign-in sheets, a routine record update, etc.

 

Data Elements that are necessary, if applicable:

Field # Data Element
9 Other insured´s or enrollee´s name – applicable if Field 11d is answered “yes”*
9a Other insured´s or enrollee´s policy/group number – applicable if Field 11d is answered “yes”*
9b Other insured´s or enrollee´s date of birth – applicable if Field 11d is answered “yes”*
9c Other insured´s or enrollee´s plan name (employer, school, etc) – applicable if Field 11d is answered “yes”*
9d Other insured´s or enrollee´s HMO or insurer name – applicable if Field 11d is answered “yes”*
11b Subscriber´s plan name (employer, school, etc.) – applicable if health plan is a group plan
23 Prior authorization number – applicable when prior authorization is required
27 Whether assignment was accepted – applicable when assignment under Medicare has been accepted
29 Amount paid – applicable if an amount has been paid by or on behalf of the patient or subscriber or by a primary plan
30 Balance due – applicable if an amount has been paid by or on behalf of the patient or subscriber

(unless otherwise agreed to by contract)

* If answer in field 11d is “Yes”, then the data elements in fields 9, 9a, 9b, 9c, and 9d must be completed unless the physician or provider submits proof of a good faith but unsuccessful effort to obtain this information from the enrollee/insured.

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