Recent Updates
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Updated on: Dec 07, 2022
Patient Signature
Patient or Authorized Signature
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Updated on: Dec 07, 2022
Another Health Benefit Plan
Indication for additional health plans
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Updated on: Dec 07, 2022
Insurance Plan Name or Program Name
Populating the Insured's information
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Updated on: Dec 07, 2022
Other Claim ID
Property Casualty Claim Number has been designated for use by NUCC for this section.
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Updated on: Dec 07, 2022
Insured's Date of Birth and Gender
Populating the Insured's information Loop 2010BA, Segment/Data Element DMG02, DMG03
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Updated on: Dec 07, 2022
Insured's Policy Group or FECA Number
Populating the Insured's information Loop 2000B, Segment/Data Element SBR03
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Updated on: Dec 07, 2022
Claim Codes
Claim Codes Loop 2300, Segment/Data Element HI
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Updated on: Dec 07, 2022
Patient Condition Related To: Other Accident
Indicating that the patient's condition is related to an accident. Loop 2300, Segment/Data Element CLM11
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Updated on: Dec 07, 2022
Patient Condition Related To: Auto Accident
Indicating that the patient's condition is related to an auto accident. Loop 2300, Segment/Data Element CLM11
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Updated on: Dec 07, 2022
Patient Condition Related To: Employment
Indicating that the patient's condition is employment related. Loop 2300, Segment/Data Element CLM11