Insured’s Information | Medicare Billing: CMS-1450 & 837I

These slides cover how to complete the insured person’s portion on the CMS-1450 and 837I forms.

Loop 2010BA, 2330A/FL 58 A-C

Table 17: Loop 2010BA, 2330A/FL 58 A-C Fields
Insured’s Name for Primary, Secondary, and Tertiary	Source
Enter the name of the person who carries the insurance benefit. When the insurer is Medicare, this will always be the patient. This information is particularly important when Medicare isn’t the primary payer.	Patient or provider records

On the same lettered line — A, B, or C — that corresponds to the line on which you show the Medicare payer information in FLs 50-54, enter the patient’s name as shown on the health insurance (HI) card or other Medicare notice. All other entries across line A (FLs 59-66) pertain to the person named in FL 58 A.

Loop 2000B SBR/FL 59 A-C

Table 18: Loop 2000B SBR/FL 59 A-C Fields
Patient’s Relationship to Insured for Primary, Secondary, and Tertiary	Source
This field contains the National Uniform Billing Committee (NUBC) code that shows the patient's relationship to the insured people identified in FL 58, lines A, B, and C.	NUBC

If you claim payment under any of the circumstances described under FLs 58 A, B, or C, you must enter the code showing the relationship of the patient to the identified insured if this information is readily available.

You can find the codes used for Medicare claims on your MACs website. The NUBC also publishes codes in the Official UB-04 Data Specifications Manual, available by subscription.

Loop 2010BA/FL 60 A-C

Medicare requires FL 60A. FLs 60B and C are situational and only used if the patient has secondary or tertiary insurance.

Table 19: Loop 2010BA/FL 60 A-C Fields
Insured’s Unique ID for Primary, Secondary, and Tertiary - Certificate/SSN/MBI	Source
Enter the insured’s MBI number assigned by Medicare or an identification number the insurance company assigns for payers other than Medicare.	Patient or provider records

Note: Always verify the patient’s MBI on their CMS-issued Medicare card. Make sure the MBI is correctly reported on the claim. For more information about the MBI, review the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 2, Sections 50 and 50.1.

Loop 2320/FL 65 A-C

Medicare requires employment data for another payer when that payer is either primary or secondary and Medicare is the secondary or tertiary payer.

Table 20: Loop 2320/FL 65 A-C Fields
Employer Name (of the Insured) for Primary, Secondary, and Tertiary	Source
If the patient is employed, enter the employer’s name.	Patient or provider records

This field has the patient’s employer information when there are payers primary to Medicare and Workers’ Compensation (WC) or an Employer Group Health Plan (EGHP) is involved. Enter the name of the employer that offers health care coverage for the person identified on the same line in FL 58.

We’ll now review the claim information related to payers.