benefits assignment indicator

To view instructions, hover over each field.

Check the Medicare Box.

Patient's Medicare number.

Insured's name if Medicare is not primary. Leave blank if Medicare is primary. May have "SAME" when insured is the patient.

These are situational if Medicare is not primary. For Electronic claims “SAME” is not acceptable.

Patient's name - last name, first name, middle initial - must be as it appears on the Medicare Card.

Date of birth - 8 digits - MM DD YYYY entered into spaces and appropriate box checked for sex.

Enter the patient's mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.

Telephone number field not available in this format.

Check the appropriate box for patient's relationship to insured when item 4 is completed.

Enter the insured's address and telephone number. When the address is the same as the patient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.

Leave blank.

Patient status field is not available in this format.

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

Items 10a - 10c

Check "YES" or "NO" to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the State postal code. Any item checked "YES" indicates there may be other insurance primary to Medicare. Identify primary insurance information in item 11.

If Medicare is primary, enter the word "NONE". If Medicare is secondary, enter the insured's policy or group number and proceed to items 11a through 11c. This field is required on a paper claim.

Policy number and or group number of the Medigap insured preceded by "MEDIGAP", "MG", or "MGAP."

Enter the insured's birth date and sex, if different from item 23.

ANSI 5010 - This segment has been deleted.

Enter employer's name, if applicable. If there is a change in the insured's status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED." Form version 02/12: provide this information to the right of the vertical dotted line.

This field is not available in this format.

Leave blank if item 9d is completed . Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and ZIP code copied from the Medigap insured's Medigap identification card.

Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item 11.

Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier(ID) .

Patient’s Medicaid number - If patient is not enrolled in Medicaid, leave blank.

Not Needed - Medicaid automatically crosses over.

Leave blank - this is not required by Medicare.

The patient or authorized representative must sign and enter either a 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Chapter 1, “General Billing Requirements.” If the patient is physically or mentally unable to sign, a representative specified in chapter 1, may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address, relationship to the patient, and the reason the patient cannot sign. The authorization is effective indefinitely unless the patient or the patient’s representative revokes this arrangement.

NOTE: This can be “Signature on File” and/or a computer generated signature.

The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Note: The signature date field is not available in this format

Enter either a patient’s or authorized person’s signature and date or enter “Signature on File” (SOF).

Enter the date of the current illness, injury or pregnancy. For Chiropractic services, enter the date of the initiation of the course of treatment.

*Use if different information given at the claim level

Leave blank. Not required by Medicare.

If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry in this field may indicate employment related insurance coverage.

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in item 17. When a claim involves multiple referring, ordering, or supervising physicians, use a separate CMS-1500 claim form for each ordering, referring, or supervising physician.

Enter one of the following qualifiers as appropriate to identify the role that this physician (or non-physician practitioner) is performing:

Qualifier Provider Role

DN Referring Provider

DK Ordering Provider

DQ Supervising Provider

Enter the qualifier to the left of the dotted vertical line on item 17.

This block is not used after May 23, 2008.

This is not used after May 23, 2008.

Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

Enter the NPI of the referring, ordering, or supervising physician or non-physician practitioner listed in item 17. All physicians and non-physician practitioners who order services or refer Medicare beneficiaries must report this data.

Enter applicable dates (either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date), dosage, global surgery period, or other narrative information. All information listed in Item 19 and its electronic equivalent is situational.

Enter the acquisition price under “$ Charges” if the “Yes” box is checked. A “Yes” check indicates that an entity other than the entity billing for the service performed the diagnostic test. A “No” check indicates that no anti-markup tests are included on the claim. When Yes is annotated, Item 32a shall be completed.

When submitting a PS1 segment, the facility information must also be in either loop 2310D or 2420C.

The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:

Indicator Code Set

9 ICD-9-CM diagnosis

0 ICD-10-CM diagnosis

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)
• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.

Note: Up to eight diagnosis codes may be entered in priority order on electronic claims. Do not use decimal points.

ANSI 5010 - In addition: Up to 12 diagnoses may be entered.

Leave blank or enter one of the following items as applicable:

• Quality Improvement Organization (QIO) prior authorization number
• Seven-digit Investigational Device Exemption (IDE) number when used in a clinical trial
• NPI of Home Health Agency or Hospice facility when Care Plan Oversight is billed
• Ten-digit CLIA number when lab services are billed
• For ambulance claims, enter the ZIP code of the point-of-pickup for the loaded ambulance trip

Enter the date of service - 6 digits (MMDDYY) or 8-digit (MMDDYYYY) date for each procedure or service.

Enter the appropriate two-digit place of service (POS) code to identify where the item is used or the service is performed.

Enter the procedure code and up to four applicable modifiers.

This is a required field. Enter the diagnosis code reference letter (as appropriate, per form version) as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis.

Enter the charge for each listed service. Note: Nonparticipating providers may not exceed the limiting charge fee for each service.

Enter the number of days or units. For anesthesia, convert hours into minutes, if necessary, and enter the total minutes required for the procedure.

This field should be blank on all claims received after May 23, 2008. Exception: Providers who have terminated their Medicare provider numbers and were never assigned an NPI. The 1C qualifier must be in this field and there must be a comment in block 19 that this is a submission from a terminated provider.

This is only used when the exception is met and there are comments in the narrative field that the submission is from a terminated provider.

Enter the rendering provider’s NPI in the unshaded portion.

Enter the Federal Tax ID (Employer Identification Number or Social Security Number) of the provider and check the appropriate box.

Enter the patient's account number.

Check the appropriate box to indicate whether the provider accepts assignment of Medicare benefits.

Enter the total charges for the services.

Enter the total amount that the patient paid for covered services only.

Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

Enter the name and complete address including the ZIP code of the facility where the services were rendered. If the supplier is a certified mammography screening center, enter the six-digit FDA approved certification number.

Enter the provider’s billing name, address, ZIP code and telephone number.

Enter the NPI of the service facility. This is a conditional field. There should be nothing in this field unless there is a purchased test as listed in Item 20. The NPI of the provider from whom the test was purchased will be listed if this is the case.

Effective May 23, 2008 this field is not to be reported.

Enter the NPI of the billing provider or group.

Item 33b is not generally reported. However, for some Medicare policies you may be instructed to use this item; direction as to how to use this item will be in the instructions you received regarding the specific policy, if applicable.

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EDI UB-04 Claims Processing Procedures (Part 4)

Edi ub-04 claims procedures (security health plan).

EDI UB-04 Claims processing procedures: EDI UB-04 Claims completion for inpatient and outpatient services billed by hospitals, skilled nursing facilities, home health agencies and other institutional providers ( Continuation).

51. Health plan ID   – Providers’ current Medicare Provider Number.

52. Release of information certification indicator – This field indicates whether the provider has on file a signed statement from the beneficiary permitting the provider to release data to other organizations in order to adjudicate the claim. (Required)

53. Assignment of benefit certification indicator – This field shows whether the provider has a signed form authorizing the third-party insurer to pay the provider directly for the service.

54. Prior payments – payers and patient – The amount the hospital has received toward payment of this bill prior to the billing date for the payer indicated in field 50 on lines a., b., and c. for outpatient claims and all other third-party payers. (Required)

55. Estimated amount due – An estimate by the hospital of the amount due from the indicated payer in field 50 on lines a., b., and c., or from the patient (estimated responsibility less any prior payments).

56. NPI   – National Provider Identifier (Type 2 for organization required).

57.   Other Provider ID – This field is not used for provider reporting. For National use only.

58.   Insured’s name – Name of the patient or insured individual in whose name the insurance is issued as qualified by the payer organization listed in field 50 on lines a., b., and c. (Required)

59. Patient’s relationship to insured – This field contains the code that indicates the relationship of the patient to the insured individuals identified in field 58 on lines a., b., and c. (Required) when Medicare is the secondary or tertiary payer.

60. Certificate/Social Security Number/health insurance claim/identification number – The insured’s identification number assigned by the payer organization. This field allows 19 alphanumeric characters in three lines. (Required)

61.   Insured group name – The group or plan through which the health insurance coverage is provided to the insured. (Required)

62. Insurance group number   – The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered.

63. Treatment authorization codes   – A number or other indicator that designates that the treatment covered by this bill has been authorized by the payer indicated in field 50 on lines a., b., and c. (Required)

64. Document control number   – Not required.

65. Employer name of the insured   – Name of the employer that provides health care coverage for the insured individual identified in field 58 on lines a., b., and c. This field allows for 24 alphanumeric characters on each of three lines. (Required)

UB-04 Claims Processing Procedures (Part 1) 

UB-04 Claims Processing Procedures (Part 2)

UB-04 Claims Processing Procedures (Part 3)

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What is Assignment of Benefits in Medical Billing?

An assignment of benefits is the act of signing documentation authorizing a health insurance company to pay a physician directly. In other words, the insurance company can pay claims without the direct involvement of the patient in the process. There are other situations where AOBs can be helpful, but we’ll focus on their use in relation to medical benefits.

If there isn’t an assignment of benefits agreement in place, the patient would be responsible for paying the other party directly from their own pocket, then filing a claim with their insurance provider to receive reimbursement. This could be time-consuming and costly, especially if the patient has no idea how to file a claim.

The document is typically signed by patients when they undergo medical procedures. The purpose of this form is to assign the responsibility of payment for any future medical bills that may arise after the procedure. It’s important to note that not all procedures require an AOB.

An assignment of benefits agreement might be utilized to pay a medical practitioner the patient didn’t choose, like an anesthesiologist. The patient may have picked a surgeon, but an anesthesiologist assigned on the day of the procedure might issue a separate bill. They’re, in essence, signing that anyone involved in their treatment can receive direct payment from the insurance carrier. It doesn’t have to go through the patient.

This document can also eliminate service fees surrounding processing. As a result, the patient can focus on medical treatment and recovery without being bogged down with the complexities of paying medical bills. The overall intent of an assignment of benefits agreement is to make the process more manageable for the patient, as they don’t need to haggle directly with their insurer.

List of Providers and Services

When the patient signs an AOB agreement, they give a third party right to obtain payment for services the provider performed, and medical billing services are a prime example of where they may sign an AOB agreement.

• Ambulance services
• Medical insurance claims
• Drugs and pharmaceuticals
• Diagnostic and clinical lab services
• Emergency surgical center services
• Dialysis supplies and equipment used in the home
• Physician services for Medicare and Medicaid patients

Services of professionals other than a primary care physician, which includes:

• Physician assistants
• Clinical nurse specialists
• Clinical social workers
• Clinical psychologists
• Certified registered nurse anesthetists

Information Commonly Requested on Assignment of Benefits Form:

• Signature of patient or person legally responsible
• Signature of parent or legal guardian

How AOBs Affect the Medical Practitioner

A medical provider or their administrative staff may feel overwhelmed by the sheer number of forms patients must fill out prior to treatment. Demanding more paperwork from patients may be seen as an added burden on the managerial staff, as well as the patient. However, getting a signed AOB is vital in preserving the interests of everyone involved.

In addition to receiving direct payment from the insurance company without needing to go through the patient, a signed assignment of benefits form will help medical providers appeal denied and underpaid claims. They can ask that payments be made directly to them rather than through the patient. This makes the process more manageable for both the doctors and the patient.

Things to Bear in Mind

The patient gives their rights and benefits to third parties under their current health plan. Depending on the wording in the AOB, their insurer may not be allowed to contact them directly about their claims. In addition, the patient may be unable to negotiate settlements or approve payments on their behalf and enable third parties to endorse checks on behalf of the patient. Finally, when the patient signs an AOB, the insurer may sue the third parties involved in the dispute.

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Pub 100-04 Medicare Claims Processing: Crossover of Assignment of Benefits Indicator (CLM08) From Paper Claim Input

Guidance announcing that system changes are being made to the manner in which the shared system sets the CLM08 value in the Coordination of Benefits (COB) flat file. Language is being modified in the Internet Only Manual Form CMS-1500 submission requirements related to box 13 which clarifies the COB ramifications of completing or not completing box 13 of the Form CMS-1500.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: November 02, 2007

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Assignment of Benefits Set to No - Signature on File Preference

Answer ID 159

Access: Everyone

The Assignment of Benefits indicates whether or not to print Signature on File. If Signature on File does not appear on a printed claim, then the insurance payment would be mailed to the patient.  The only difference for eClaims is that it is indicated by a Y or N.

To check setup for Signature on File:

• Go to the Lists | Person , edit the Policy Holder , and click on Preferences .
• Under Insurance Preferences , make sure the box for Signature on File is checked.
• Close out of the Preferences window and click to open the  Employer/Coverage list. 
• Edit the patient's employer.  Click on the Preferences box to the right.
• Make sure the box for Authorize Payment to the Office is checked and the Calculation Method is set to either Estimate Insurance or Insurance Co. Responsible for All .

If these areas were already setup correctly but the Assignment of Benefits was set to N (no) it might have been changed just on that one claim.

• Find the claim in question in the claims window, then click the Change Answers button.
• Verify if the " Authorize Payment to Office " checkbox at the top is unchecked.
• If it's unchecked, then you can check mark it and resubmit the claim. This box could have been unchecked during the walkout process.

Printed copies of this document are considered uncontrolled.

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Consumer Insight

Sept. 13, 2023

Assignment of Benefits: Consumer Beware

You've just survived a severe storm, or a tornado and you've experienced some extensive damage to your home that requires repairs, including the roof. Your contractor is now asking for your permission to speak with your insurance company using an Assignment of Benefits. Before you sign, read the fine print. Otherwise, you may inadvertently sign over your benefits and any extra money you’re owed as part of your claim settlement.

The National Association of Insurance Commissioners (NAIC) offers information to help you better understand insurance, your risk and what to do in the event you need repairs after significant storm damage.

Be cautious about signing an Assignment of Benefits. An Assignment of Benefits, or an AOB, is an agreement signed by a policyholder that allows a third party—such as a water extraction company, a roofer or a plumber—to act on behalf of the insured and seek direct payment from the insurance company.  An AOB can be a useful tool for getting repairs done, as it allows the repair company to deal directly with your insurance company when negotiating repairs and issuing payment directly to the repair company. However, an AOB is a legal contract, so you need to understand what rights you are signing away and you need to be sure the repair company is trustworthy.

• With an Assignment of Benefits, the third party, like a roofing company or plumber, files your claim, makes the repair decision and collects insurance payments without your involvement.
• Once you have signed an AOB, the insurer only communicates with the third party and the other party can sue your insurer and you can lose your right to mediation.
• It's possible the third party may demand a higher claim payment than the insurer offers and then sue the insurer when it denies your claim.
• You are not required to sign an AOB to have repairs completed. You can file a claim directly with your insurance company, which allows you to maintain control of the rights and benefits provided by your policy in resolving the claim.

Be on alert for fraud. Home repair fraud is common after a natural disaster. Contractors often come into disaster-struck regions looking to make quick money by taking advantage of victims.

• It is a good idea to do business with local or trusted companies. Ask friends and family for references.
•  Your insurer may also have recommendations or a list of preferred contractors.
• Always get more than one bid on work projects. Your adjuster may want to review estimates before you make repairs.

Immediately after the disaster, have an accurate account of the damage for your insurance company when you file a claim.

• Before removing any debris or belongings, document all losses.
• Take photos or video and make a list of the damages and lost items.
• Save damaged items if possible so your insurer can inspect them, some insurance companies may have this as a requirement in their policy.

Most insurance companies have a time requirement for reporting a claim, so contact your agent or company as soon as possible. Your  state insurance department  can help you find contact information for your insurance company, if you cannot find it.

• Insurance company officials can help you determine what damages are covered, start your claim and even issue a check to start the recovery process.
• When reporting losses, you will need insurance information, current contact information and a  home inventory or list of damaged and lost property . If you do not have a list, the adjuster will give you some time to make one. Ask the adjuster how much time you have to submit this inventory list. The NAIC Post Disaster Claims Guide has details on what you can do if you do not have a home inventory list.

After you report damage to your insurance company, they will send a claims adjuster to assess the damage at no cost to you . An adjuster from your insurance company will walk through and around your home to inspect damaged items and temporary repairs you may have made.

• A public adjuster is different from an adjuster from your insurance company and has no ties to the insurance company.
• They estimate the damage to your home and property, review your insurance coverage, and negotiate a settlement of the insurance claim for you.
• Many states require public adjusters to be licensed. Some states prohibit public adjusters from negotiating insurance claims for you. In those states, only a licensed attorney can represent you.
• You have to pay a public adjuster.
• The NAIC Post Disaster Claims Guide has information on the different types of adjusters.

Once the adjuster has completed an assessment, they will provide documentation of the loss to your insurer to determine your claims settlement. When it comes to getting paid, you may receive more than one check. If the damage is severe or you are displaced from your home, the first check may be an emergency advance. Other payments may be for the contents of your home, other personal property, and structural damages. Please note that if there is a mortgage on your home, the payment for structural damage may be payable to you and your mortgage lender. Lenders may put that money into an escrow account and pay for repairs as the work is completed.

More information. States have rules governing how insurance companies handle claims. If you think that your insurer is not responding in a timely manner or completing a reasonable investigation of your claim, contact your  state insurance department .

About the National Association of Insurance Commissioners

As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. The U.S. standard-setting organization is governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer reviews, and coordinate regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally.

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More on Loop 2320 OI/Item 13

The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if you included necessary 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 of service or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it’s revoked.

We’ll now review the claim information in this section of Lesson 4 relevant to Medicare Secondary Payer (MSP).

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.

  Enter Other Payer

In addition to NY Medicaid, you may enter additional payers who are responsible for this claim. Remember that all elements marked with an asterisk ( * ) are required when entering a Payer. Not all claims will have Other Payer information. Note: A maximum of 10 Other Payer records may be entered per claim.

Other Payer Information

Other Payer Name: Select the name of the desired payer from the provided list. If the Other Payer you are looking for is not listed, contact your Administrator to add the Payer to the Support File of valid Payers. Required for all Other Payers. Payer Sequence Number: Select the value that represents the order in which payment was received from other payers. Payers may be entered in any sequence and displayed in any sequence. Required for all Other Payers.

Payer Type: A code identifying the type of Payer. Enter or select a value from the list of available codes.

Other Payer Paid Amount: This field is required when this payer has adjudicated the claim. If the Other Payer denied the claim, enter 0. If the Other Payer has not adjudicated the claim, leave blank. If a value is entered, the Date Claim Paid must be entered as well.

Other Payer Claim Control Number:  Enter the claim control number of the other payer.

Date Claim Paid: Date on which the Other Payer Paid Amount was received. This date may not be greater than the current date. The format is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.

Other Subscriber

Last Name/First Name: If entering an Other Payer, you must enter the First and Last Name of the Subscriber for the Payer. The Subscriber may or may not be the Client.

Primary ID: The Other Insured Identifier as assigned by the Payer. This is required when entering the Subscriber for the Other Payer.

Address Line 1/2: The street address of the Subscriber, if known.

City: Enter city name of the Subscriber.

State: State in which the Subscriber lives. Select value from the list of available valid state abbreviations, defaults to 'NY'.

Zip Code: Enter the postal Code associated with the Subscriber's address.

Country: Country in which the Subscriber lives. Select value from the list of available countries, defaults to 'US'.

Other Subscriber Information

Relationship: Code indicating the relationship between the Client/Patient and the Subscriber for this Payer. Enter or select a value from the list of available codes. A relationship is required if a Subscriber is entered.

Group Number: Enter the Subscriber’s group number for the other payer when applicable.

Group Name: The Group Name associated with the Group Number above.

Claim Adjustments

If the other payer reported claim adjustments at the claim level, enter the adjustment information here. Otherwise, this information will be blank. Claim adjustment group codes and reason codes are from the remittance of the other payer.

Claim Adjustment Group: Enter the Group Code as received from the other payer. A maximum of 5 Claim Adjustment Groups are allowed per claim and the values are to be entered. Reason Code: Enter the Claim Adjustment Reason Code as received from the other payer. The Claim Adjustment Group/Reason Code combination may not be entered more than once. If an Adjustment Amount or Adjustment Quantity is entered, a Reason Code is required. Adjustment Amount: Enter the Adjustment Amount as received from the other payer. Adjustment Quantity: Enter the Quantity Adjusted as received from the other payer.

Other Insurance Coverage Information

Assignment of Benefits?: The Benefits Assignment Certification Indicator. 'Yes' indicates insured or authorized person authorizes benefits to be assigned to the provider while 'No' indicates that no authorization has been given. This value will default to 'Yes' and is required if an Other Payer Name is selected.

Patient Signature Source: Enter or select the Patient Signature Source Code, indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. An entry is required if an Other Payer Name is selected.

Release of Information?: Indicates whether the provider has a signed statement by the patient authorizing the release of medical data to other organizations. This value is required if an Other Payer Name is selected.

Remaining Patient Liability: This is the amount the provider believes is due and owing after the Other Payer’s adjudication.

Non-Covered Charge Amount: Enter the dollar value of the claim in this field if the other payer was not billed, and documentation is on file that the other payer would not have paid the claim.

Once all the information for the Payer has been added, another payer may be added by clicking the Next Payer>> control at the top or bottom of the tab. This will return you to the top of the page with all the values cleared out and a new Payer Number listed at the top of the page. Clicking View All Other Payers will display the Other Payers Summary page.

Click = 4 && typeof(BSPSPopupOnMouseOver) == 'function') BSPSPopupOnMouseOver(event);" class="BSSCPopup" onclick="BSSCPopup('../Tab_Controls.htm');return false;">here for the controls located at the bottom of the page or continue to the Service Line(s) tab.