HCFA BOX BLOCK 9 OTHER INSURED’S NAME
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in block 2. Otherwise, enter the word “SAME”. If no Medigap benefits are assigned, leave blank.
BLOCK 9A OTHER INSURED’S POLICY OR GROUP NUMBER
Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG or MGAP.
BLOCK 9B OTHER INSURED’S DATE OF BIRTH
Enter the Medigap enrollee’s birth date (MMDDCCYY) and sex.
BLOCK 9C EMPLOYER’S NAME OR SCHOOL NAME
Disregard “employer’s name or school name” which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code , and ZIP code copied from the Medigap insured’s Medigap identification card. For example:
1257 Anywhere Street Baltimore, MD 21204
is shown as “1257 Anywhere St MD 21204.”
Note: If a carrier assigned unique identifier of a Medigap insurer appears in block 9D, block 9C may be left blank.
BLOCK 9D INSURANCE PLAN NAME OR PROGRAM NAME
Enter the name of the Medigap insured’s insurance company or the Medigap insurer’s unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in block 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.
Completion of fields 9A-D are conditional for insurance information related to Medigap.
BLOCK 10A THROUGH 10C IS PATIENT’S CONDITION RELATED TO:
Check “YES” or “NO” to indicate whether employment, auto accident or other accident (i.e., liability suit) involvement applies to one or more of the services described in block 24. Enter the state postal code. Any item checked “YES” indicates there may be other insurance primary to Medicare. Identify primary insurance information in block 11.
Completion of fields 10A-C are required for all claims; “Yes” or “No” must be indicated.
BLOCK 10D RESERVED FOR LOCAL USE
Use this block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by “MCD”.
BLOCK 11 INSURED’S POLICY, GROUP OR FECA NUMBER
When submitting paper or electronic claims, block 11 must be completed. By completing this information, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is the primary or secondary payer. Claim without this information will be returned or rejected.
Note: If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to blocks 11a-11c.
If there is no insurance primary to Medicare, enter the word “NONE” in block 11 and proceed to block 12.
If the insured reports a terminating event with regard to insurance which had been primary to Medicare (e.g., insured retired), enter the word “NONE” and proceed to block 11b.
Completion of block 11 (i.e., insured’s policy/group number or “NONE”) is required on all claims.
Completion of blocks 11B-C are conditional for insurance information primary to Medicare.
Insurance Primary to Medicare – Circumstances under which Medicare payment may be secondary to another insurance include:
Group Health Plan Coverage: – Working Aged; – Disability (Large Group Health Plan); and – End Stage Renal Disease.
No Fault and/or other Liability;
Work-Related Illness/Injury: – Workers’ Compensation; – Black Lung; and – Veterans Benefits.
Note: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer’s explanation of benefits (EOB) notice must be forwarded along with the claim form.
BLOCK 11A INSURED’S DATE OF BIRTH
Enter the insured’s birth date (MMDDCCYY) and sex, if different from block 3.
BLOCK 11B EMPLOYER’S NAME OR SCHOOL NAME
Enter the employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the six – digit retirement date (MMDDYY) preceded by the word “RETIRED.”
Completion of this field is conditional when the beneficiary has insurance primary to Medicare.
BLOCK 11C INSURANCE PLAN NAME OR PROGRAM NAME
Enter the complete insurance plan or program name, e.g., Blue Shield of (State). If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB.
Completion of this field is conditional for insurance information primary to Medicare.
BLOCK 11D IS THERE ANOTHER HEALTH BENEFIT PLAN
Leave blank. Not required by Medicare.
