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Health Care Claim Preparation & Transmission Chapter 8 OT 232 Lecture 2 1OT 232 Ch 8 lecture 1.

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Presentation on theme: "Health Care Claim Preparation & Transmission Chapter 8 OT 232 Lecture 2 1OT 232 Ch 8 lecture 1."— Presentation transcript:

1 Health Care Claim Preparation & Transmission Chapter 8 OT 232 Lecture 2 1OT 232 Ch 8 lecture 1

2 Completing the CMS-1500 Claim (cont’d) – IN 32 Service Facility Location Information – Used for information if different than IN33 – Used for providers of diagnostic tests or radiology services – IN 33 Provider’s billing info Taxonomy codes – Another form of id that stands for a physician’s specialty – Used also if pay can be affected – Appendix A, page 633 Awesome summary for CMS-1500, page OT 232 Ch 8 lecture 1

3 Completing the HIPAA 837 Claim 837 P – ‘P’ stands for professional services – Used by physicians 837 I – ‘I’ stands for institutional – Used by hospitals PMP vendors are responsible for – Keeping the product up-to-date – Getting certification from HIPAA that their software accommodates HIPAA-mandated transactions – Train personnel to use new features 3OT 232 Ch 8 lecture 1

4 Completing the HIPAA 837 Claim (cont’d.) PMP’s pull data elements to complete form – Pieces of information – 4 types R – Required RIA – Required if applicable – Ex. insured differs from patient NRUC – Not required unless specified under contract – Flex boxes NR – Not required – In provider’s records but payer doesn’t need, or already has this info 837 is organized differently than the 1500 – More efficient There is a hierarchy to how info is sent, so the only data elements that have to be sent are those that don’t repeat previous data 4OT 232 Ch 8 lecture 1

5 Completing the HIPAA 837 Claim (cont’d.) – Provider info So if a batch of claims is sent, provider data is sent once and used for all 4 types of providers – Billing provider » Sending the claim – Pay-to provider » Person or organization that will receive payment for services reported on the claim – Rendering provider » Medical professional who provides the service being reported – Referring provider » Physician who refers the patient to another physician for treatment – One claim could involve all 4 » Dr. A is the referring provider who refers the patient to the rendering physician Dr. B who works for the pay-to provider, Clinic C, and Clinic C uses a clearinghouse as a billing provider to transmit its claims. Whew! – Or one… » The rendering provider bills for his services and receives payment! 5OT 232 Ch 8 lecture 1

6 Completing the HIPAA 837 Claim (cont’d.) – Subscriber and patient info 1500 uses ‘insured’, 837 uses ‘subscriber’ (Many benefits to electronic form, including more options) Claim filing indicator code – Identifies type of plan – Valid until a National Payer ID system is in place – Table 8.5 on page 268 Relationship of Patient to Subscriber – Vs. 1500? – Table 836, page 269 Other data elements – Used if another payer is involved – Patient-specific information 6OT 232 Ch 8 lecture 1

7 Completing the HIPAA 837 Claim (cont’d.) – Payer info Payer obviously knows it’s own info, but helpful for CoB – Coordination of Benefits Remember the order of responsible payers? Primary… – Secondary, Tertiary, Supplemental – Claim info Info related to a particular claim Claim Control Number – Unique for each claim, NOT the patient’s account number Claim Frequency Code – Aka ‘Claim Submission Reason Code’ » ‘1’ on the initial claim » ‘7’ on a replacement claim (so they know it’s not a double bill) » ‘8’ to cancel prior claim 7OT 232 Ch 8 lecture 1

8 Completing the HIPAA 837 Claim (cont’d.) Diagnosis Code – Different from 1500, because can list 8 » (4 on 1500) – Still must be directly related to treatment Claim note – “flex box” – Service Line Information Diagnosis Code Pointers – From codes, links to procedures Line Item Control Number – Tracks for services rather than claims – Service lines are numbered by sender, so easier to match up when payments are made 8OT 232 Ch 8 lecture 1

9 Completing the HIPAA 837 Claim (cont’d.) – Claim Attachments Separate page of info to support the claim Currently no standard form – Credit/Debit info Consent form to bill after adjudication Clearinghouses and Claim Transmission – Check claims – Transmit claims Directly 9OT 232 Ch 8 lecture 1

10 Claim Transmission (cont’d.) Clearinghouse – Benefits? » Accept nonstandard formats and translates them into standard » Maps the content of each data element according to the payer’s instructions Cannot create or modify data, ‘fix’ the claim » Edits the claim and returns to provider for corrections or missing information Direct Data Entry – DDE – Web based claim form – Billing providers enters info which goes straight to the payers Clean claims vs. Dirty Claims 10OT 232 Ch 8 lecture 1


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