Claim Forms: Referral Information - Box 10a-c, 16, 18, 23
The Referral Information section of Healthie claim form collects various information that may be needed for claim approval. You'll find more information on completing the Referring Provider section of the form here.
Include Referrer Information on CMS 1500
Check the box if you'd like Referring Provider details to be added to the CMS 1500 Claim form. This is necessary if a referral is required for services to be reimbursed by the insurance payer. Please check with the insurance payer to verify if a referral is required.
Condition Related To (Box 10a, 10b, 10c)
You'll be prompted to make one of the following selection (if one applied)
- Employment (Past/Present) - indicating that the client's condition they are seeking services for are related to a workplace injury
- Auto Accident
- Other Accident
Dates Unable to Work in Current Occupation (Box 16)
If client has been unable to work related to this condition, please enter a corresponding start/end date.
Please be sure to fill out the correct date fields.
Dates Hospitalized Related to this Condition (Box 18)
If client has been hospitalized related to this condition, please enter a corresponding start/end date.
Please be sure to fill out the correct date fields.
Prior Authorization Number (Box 23)
For some insurance policies, prior authorization is required before the service is rendered in order for services to be reimbursed. Please contact the insurance payer directly to obtain prior authorization. Once you receive an authorization number, you can document it in the claim form.