New HCFA
A new Health Insurance Claim Form (HCFA) has been released, which goes into effect January 6, 2014. Some of the changes to be aware of include:
• Use commas to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names. Do not use periods within the name.
• 8-digit dates must be used in all date-of-birth fields (items 3, 9b, and 11a),
• Leave Box 8 blank
Also please note the following for individual boxes on the form:
Box 11 Insured’s Policy Group or FECA Number:
•
11b Other Claim ID (Designated by NUCC)
Enter the “Other Claim ID.” Applicable claim identifiers are designated
by the NUCC. The following qualifier and accompanying identifier has been
designated for use:
Y4 Property Casualty Claim Number
Enter the qualifier to the left of the vertical dotted line.
Enter the identifier number to the right of the vertical dotted line. For example:
Box 14 Date of Current Illness, Injury, or Pregnancy (LMP)
•
QUAL.:
To the right of the vertical dotted line, enter the applicable qualifier
to identify which date is being reported (431), onset of current symptoms
or illness (484), or last menstrual period.
Box 15 Other Date
•
QUAL.:
To the right of the vertical dotted line, enter the applicable qualifier
to identify which date is being reported:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-ray
471 Prescription
090 Report Start
091 Report End
444 First Visit or Consultation
Box 17 Name of Referring Provider or Other Source
Before the vertical dotted line, enter the applicable qualifier to identify which provider is being reported:
DN Referring Provider
DK Ordering Provider
DQ Supervising Provider
Box 21 Diagnosis or Nature of Illness or Injury
Between the vertical dotted lines, enter the applicable ICD indicator to identify which version of ICD codes is being reported:
9 ICD-9-CM
0 ICD-10-CM
Relate lines A - L to the lines of service in 24E by the letter of the line.
For specifics, please refer to the Medicare Claims Processing Manual, Chapter 26.