HCFA 1500 - Physicians and Non-Institutional Providers
Data Elements that are necessary, if applicable
(unless otherwise agreed to by contract)
| 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 |
* 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.
For more information contact: ConsumerProtection@tdi.state.tx.us
Texas Department of Insurance
