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