Box 11. - INSURED'S POLICY GROUP OR FECA NUMBER

patient/guarantors/guarantor#/ellipse button/open/policy & coverage/group plan #

for primary guarantor

Medicare (per CH. 26 of the CMS billing Manual) : Item 11 - THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.

If there is no insurance primary to Medicare, enter the word "NONE" and proceed to item 12.

If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c. Items 4, 6, and 7 must also be completed. NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11. Note - Medicare is primary. Edit the primary guarantor who is Medicare, in the policy info enter the word 'None' in the Group Plan # box.

Note - Enter the insured’s policy or group number as it appears on the insured’s health care identification card in the Group plan # field. If Item Number 4 is completed, then this field should be completed.

Note - There must be a primary guarantor selected on the condition screen for this to print

Note - In CA, FL; if primary is Medicare, "NONE" prints in box 11 for paper only. (May in other states also)

Note - 7/10/14 and above. In VT, allows SecGrp(plan)# to print in box 11 instead of 'NONE' when Medicare is secondary.

Note - 6/1/17 and above. In PA, allows SecGrp(plan)# to print in box 11 instead of 'NONE' when Medicare is secondary.