Question

12. Name the three sections of the claim form .

13. Identify information required to file a third-party claim. What information must be included in section 1 of claim form?

14. Name 13 pieces of information in section 2 .

Answer 1

12. Name the three sections of the claim form .

1. carrier
2. patient and insured information
3. physician or supplier information

13. Identify information required to file a third-party claim. What information must be included in section 1 of claim form?

Answer:-

The type of insurance

14. Name 13 pieces of information in section 2 .

1. insured's ID number
2. patient full name
3. patient date of birth and gender
4. insured's name
5. patient's address and telephone number
6. patient relationship to insured
7. insured's address and phone number
8. secondary insurance name
9. Secondary insurance information
10. patient's condition related to work, accident or other
11. primary policy, group, or FECA number
12. patient release of information
13. insured authorization of benefits

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