Professional Documents
Culture Documents
Kr-Insurance Comparison Chart
Kr-Insurance Comparison Chart
Insurance
Block
1
1a
2
BCBS
BCBS plan ID #
7
8
Medicare
Medicaid
x - Medicare box
x - Medicaid box
Medicare ID #
Medicaid ID #
Leave blank
leave blank
Leave blank
Leave blank
x-
leave blank(secondary
9, 9A, 9D coverage only)
9B-9C leave blank
10A-C
10D
leave blank
11
policyholder's commercial
group # is patient is covered
by group health plan.
Otherwise leave blank
11A
11B
leave blank
11C
name of policyholder's
commercial health ins. Plan
leave blank
Leave blank
leave blank
Leave blank
11D
12
13
14
leave blank
Leave blank
Leave blank
Leave blank
15-16
17
17A
17B
if applicable, referring
professional (FIRST, M, LAST,
Credentials) if applicable. In
front of name, enter applicable
qualifier to indentify which
provider is being preorted:
DN(referring), DK(ordering), or
DQ (supervising). Otherwise,
leave blank
leave blank
10-digit NPI of provider
18
19
20
21
22
leave blank(resubmitted
claims)
23
24A
24B
applicable quality
improvement organization
prior authorization #,
investigational devise
exemption #, NPI for
medicaid preauthorization
physician performing care
number, assigned by
plan oversight services, 10
payer, if applicable. If
digit clinical lab improvement written preauthoization was
amendments # or skilled
obtained, attach copy to
nursing facility NPI. If n/a,
claim. Otherwise, leave
leave blank
blank
24C
leave blank
24D
24E
24F
24G
24H
24I
24J
25
26
27
28
29-30
31
32
32A
32B
33
33A
33B
Leave blank
Tricare
Worker's Comp
Pt's employer
x - other box
If DD Form 2527 is
attached, enter DD FORM
2527 ATTACHED, otherwise
leave blank
Leave blank
Leave blank
leave blank
enter claim # assigned by
workers' compensation third
party payer
Leave blank
leave blank
leave blank
leave blank
Leave blank
leave blank