Medigap Claim Form Fields
Review these slides to fill out payer information for Medigap.
Loop 2330A NM1 / Item 9
| Other Insured’s Name | Source |
|---|---|
Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it’s different from the name shown in item 2 Patient’s Name. Otherwise, enter the word Same. If no Medigap benefits are assigned, leave this blank. Enter the insured’s name in item 9 of the CMS-1500 and Loop 2330A NM1 of the 837P. Item 9 and its sub-items, 9a and 9d, apply to Medigap only. | Patient records |
Only participating health care professionals and suppliers complete item 9 Other Insured’s Name and its subdivisions, and only when patients assign their rights to payment to the provider for Medigap purposes.
Note: This procedure only applies to the 12 Medigap plans that don’t submit eligibility files to the Benefits Coordination & Recovery Center (BCRC) to trigger Medicare’s claims crossover process.
Loop 2320 SBR03 / Item 9a
| Other Insured’s Policy or Group Number | Source |
|---|---|
Enter the policy or group number of the patient’s Medigap number preceded by MEDIGAP, MG, or MGAP for item 9a. For the 837P, enter the Insured’s Group or Policy Number in Loop 2320 SBR03. | Patient records |
Note: You must complete item 9d, even when the provider enters a policy or group number in item 9a.
Loop 2330B NM109 / Item 9d
| Insurance Plan Name or Program Name | Source |
|---|---|
Enter the 5-byte Coordination of Benefits Agreement (COBA) Medigap claims-based Identifier (ID). On the 837P, enter the Other Insured Group Name in Loop 2320 SBR04. | COBA Trading Partners |
More on Loop 2330B / Item 9d
Most Part A and Part B claims automatically cross over to other insurance companies that pay after Medicare, like Medigap plans, no matter what’s on the Medicare claim. This happens because of contracts between the insurer and CMS’s Benefits Coordination & Recovery Center (BCRC). The insurer sends an eligibility file to the BCRC listing all their covered members, making this automatic crossover possible.
Medicare still offers a simplified process for Medigap claims crossover. This process is triggered by the information in item 9 and its sub-items 9a-9d of the CMS-1500.
Before filling out these items, check the list of Medigap claim-based COBA IDs to see if the patient’s Medigap insurer participates in this process. If the patient’s Medigap insurer is on the list, enter the BCRC-assigned 5-byte Medigap claim-based COBA ID, ranging from 55000 to 59999, in item 9d.
Loop 2320 OI03 / Item 13
| Insured’s or Authorized Person’s Signature | Source |
|---|---|
The patient’s signature or the words signature on file in this item authorizes payment of medical benefits to the health care professional or supplier. Note: In addition to populating the 2320 OI03 segment, information from item 13 also populates the 2300 CLM08 Benefits Assignment. | Patient or Medicare records |
More on Loop 2320 OI / Item 13
Some important details about Medigap benefits authorization:
- The signature in item 13 authorizes payment of mandated Medigap benefits to the participating physician or supplier if you included Medigap information in item 9 and its subdivisions
- The patient or their authorized representative signs this item or the signature must be on file as a separate Medigap authorization
- The Medigap assignment on file in the participating provider or supplier’s office must specify the insurer
- It may state that the authorization applies to all occasions of service until it’s revoked
Authorized Signature
You can use a signature on file or a computer-generated signature. Electronic claims include an Assignment of Benefits Indicator or a Release of Information Code in Loop 2320.