FORM FIELD | REQUIRED | DESCRIPTION |
Element 01-Program Block/Claim Sort Indicator | YES | |
Element 01a–Insured's I.D. Number | YES | All claims require one of the following recipient numbers in order for processing. Enter the recipient's Alien Identification Number. If not available, enter recipient's Fingerprint ID Number. If not available, enter recipient's Event Number. Do not enter any other numbers or letters. It is the referring custodial facility's responsibility to provide this information to the provider. |
Element 02 – Patient's Name | YES | Enter the recipient's last name, first name, and middle initial. |
Element 03 – Patient's Birth Date, Patient's Sex | YES | Enter the recipient's birth date in MM/DD/YY format (e.g., February 3, 1955, would be 02/03/55) or in MM/DD/YYYY format (e.g., February 3, 1955, would be 02/03/1955). Specify whether the recipient is male or female by placing an “X” in the appropriate box. |
Element 04 – Insured's Name | YES | |
Element 05 – Patient's Address | YES | Enter the detention facility's address where the recipient resides. If recipient in custody of Border Patrol, enter the Border Patrol Station of the Border Patrol Officer(s). Do not use the detainee's home address. |
Element 06 - Patient Relationship to Insured | | |
Element 07 – Insured's Address | YES | Enter the detention facility's address where the recipient resides. If recipient in custody of Border Patrol, enter the Border Patrol Station of the custodial Border Patrol Officers. |
Element 08 - Patient Status | | |
Element 09 -Other Insured's Name | | |
Element 10 - Is Patient's Condition Related to | YES | |
Element 11 – Insured's Policy, Group, or FECA Number | YES | |
FORM FIELD | REQUIRED | DESCRIPTION |
Element 11a – Insured's Date of Birth and Sex | YES | |
Element 11b - Employer's Name or School Name | | |
Element 11c - Insurance Plan Name or Program Name | YES | Enter “Immigration Health Services.” |
Elements 12 and 13 - Authorized Person's Signature | YES | |
Element 14 -Date of Current Illness, Injury, or Pregnancy | | |
Element 15 - If Patient Has Had Same or Similar Illness | | |
Element 16 -Dates Patient Unable to Work in Current Occupation (not required) | | |
Elements 17 and 17a - Name and I.D. Number of Referring Physician or Other Source | YES WHEN APPLICABLE | |
Element 18 -Hospitalization Dates Related to Current Services | YES WHEN APPLICABLE | |
Element 19 - Reserved for Local Use | | |
Element 20 -Outside Lab? | | |
Element 21 -Diagnosis or Nature of Illness or Injury | YES | Enter the most current International Classification of Diseases, Clinical Modification (ICD-9-CM) diagnosis code for each symptom or condition related to the services provided. List the primary diagnosis first. |
Element 22 - Medicaid Resubmission | | |
Element 23 - Prior Authorization Number | YES | Enter the Authorization # for service. All Claims require an Authorization # for processing. It is the referring custodial facility's responsibility to provide this information to the provider. |
Element 24A - Date(s) of Service | YES | Enter the ... |