Claim Page 06 — Entering a Hospice Claim
Claim Page 06 (Map 1716) contains additional insurer information (when Medicare is secondary), and also contains payment information upon processing of the claim. If you are submitting a Medicare Secondary Payer (MSP) claim, completing the MSP ADDITIONAL INSURER INFORMATION area on Claim Page 06 is required.
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 06 – Map 1716
The HIC, TOB, S/LOC, and PROVIDER fields are system generated from information on Claim Page 01.
| Field Name / Requirement | Description |
|---|---|
| 1ST INSURERS ADDRESS 1, 2 Conditionally Required |
Primary insurance company’s mailing address. |
| CITY Conditionally Required |
Primary insurance company’s city. |
| ST Conditionally Required |
Primary insurance company’s state. |
| ZIP Conditionally Required |
Primary insurance company’s zip code. |
| 2ND INSURERS ADDRESS 1, 2 Conditionally Required |
Secondary insurance company’s mailing address. |
| CITY Conditionally Required |
Secondary insurance company’s city. |
| ST Conditionally Required |
Secondary insurance company’s state. |
| ZIP Conditionally Required |
Secondary insurance company’s zip code. |
Page last updated: March 18, 2008
