Health Insurance Claim Form - NUCC 02/12

Submit the completed Health Insurance Claim Form to the designated address or online portal provided in the instructions. For physical submission, mail the form to the address listed: MASSACHUSETTS LABORERS' H&W FUND, PO BOX 1501, 1400 DISTRICT AVENUE; STE 200, BURLINGTON, MA 01803-1501. For online submission, follow the specific instructions provided by your insurance provider or healthcare program.

For the years 2024 and 2025, make sure to stay updated with changes or updates in form requirements by the NUCC and relevant health programs.

The Health Insurance Claim Form is essential for submitting health insurance claims for services rendered. It is used by patients, healthcare providers, and insurance companies to request payment for medical care provided. The form ensures that all necessary information is accurately provided to process the claim efficiently. Completing this form accurately is crucial for avoiding delays or denials in claim processing. The form requires detailed information about the patient, insurance coverage, medical services provided, and any diagnoses or procedures. Submitting an accurate claim helps streamline the payment process and ensures that healthcare providers are compensated for their services. The Health Insurance Claim Form is also used by various government health programs such as Medicare and Medicaid. It is important to follow the specific guidelines provided by these programs to ensure that the claim is processed correctly. By using this form, you help maintain the integrity and efficiency of the health insurance claim process.

• 1. Patient's Name: Enter the patient's last name, first name, and middle initial.
• 2. Patient's Address: Provide the patient's street address, city, state, and ZIP code.
• 3. Patient's Birth Date: Enter the patient's birth date in DD/MM/YYYY format.
• 4. Patient's Sex: Indicate the patient's sex by checking the appropriate box (M/F).
• 5. Insured's ID Number: Enter the insured's identification number or Member ID.
• 6. Insurance Plan Name: Provide the name of the insurance plan or program.
• 7. Medical Record Number: Enter the medical record number relevant to the claim.
• 8. Patient's Condition Related To: Check whether the patient's condition is related to employment, an auto accident, or another accident.
• 9. Claim Codes: Enter the designated claim codes as provided by NUCC.
• 10. Signature: The patient's or authorized person's signature to release medical information and request payment of benefits.
• 11. Diagnosis Codes: Enter the diagnosis or nature of illness or injury codes.
• 12. Procedure Codes: Provide the codes for the procedures, services, or supplies provided.
• 13. Provider Information: Include the physician's or supplier's information, including NPI and signature.
• 14. Total Charge: Enter the total charges for the services rendered.
• 15. Amount Paid: Provide the amount already paid, if applicable.
• 16. Billing Provider Info: List the billing provider's information and contact details.

Failure to submit the Health Insurance Claim Form may result in delays or denial of claim processing. Ensure accurate and timely submission to avoid issues.

• Delayed Payment: Submitting the form late can delay the payment process for medical services rendered.
• Claim Denial: Errors or missing information can lead to claim denial, requiring resubmission and further delays.
• Out-of-Pocket Costs: Failure to submit the form may result in out-of-pocket costs for the patient.

• 1. Medical Care Claims: Submit claims for medical services received by the patient.
• 2. Insurance Reimbursement: Request reimbursement from health insurance providers.
• 3. Government Health Programs: Submit claims to programs like Medicare and Medicaid.
• 4. Employer Health Benefits: File claims for employee health benefit plans.
• 5. Treatment Authorization: Use the form to authorize treatment and request payment.