Claim Page 05 — Entering a Hospice Claim

Claim page 05 (Map 1715) contains the insured person(s) information (when Medicare is secondary). Claim Page 05 must be completed when Medicare is not the primary payer.

FISS Claims Entry Page 5, entering hospice claims

Key:

RED = Required field
BLUE = Optional field
GREEN = Conditional field, depended on the type of claim
PURPLE = System generated field
BLACK = Not required field

Field Descriptions for Claim Page 05 – Map 1715

The HIC, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.

Field Name	Description
INSURED NAME Conditionally Required	Name of policyholder, last name and first name. When Medicare is not primary, enter the information for the person who carries the primary insurance on Line A. Enter the beneficiary’s information on Line B (when Medicare is secondary) or Line C (Medicare is tertiary).
REL Conditionally Required	Relationship code of patient to the insured. When Medicare is not the primary payer, enter a code indicating the relationship of the patient to the insured.
CERT.-SSN-HIC Conditionally Required	Certificate/Social Security No./Health Insurance Claim No./Identification No. The beneficiary’s Health Insurance Claim Number (HICN) will be system generated on line A when Medicare is the primary payer. When Medicare is not the primary payer, enter the appropriate payer number.
SEX Conditionally Required	Identifies the sex of the insured.
GROUP NAME Conditionally Required	Name of group (payer/other coverage). When Medicare is not the primary payer, enter the name of the group or plan for the primary payer.
DOB Conditionally Required	Identifies the insured’s date of birth.
INS GROUP NUMBER Conditionally Required	Insurance policy group number. When Medicare is not the primary payer, enter the number of the group or plan for the primary payer.

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Hospice Relationship Codes

Code	Title	Code	Title
01	Spouse	23	Sponsored dependent
04	Grandfather or Grandmother	24	Dependent or minor dependent
05	Grandson or Granddaughter	29	Significant Other
07	Nephew or niece	32	Mother
10	Foster child	33	Father
15	Ward	36	Emancipated minor
17	Stepson or stepdaughter	39	Organ donor
18	Self	40	Cadaver donor
19	Child	41	Injured plaintiff
20	Employee	43	Child where insured has no financial responsibility
21	Unknown	53	Life partner
22	Handicapped dependent	G8	Other relationship

Page last updated: March 26, 2008