Medical Insurance Claims Lesson 3: The CMS-1500 18 Medical Insurance Claims Lesson 3: The CMS-1500

Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. List the information required on a medical claim form and explain why each piece of information is needed. Discuss legal issues affecting medical claims submission. Discuss insurance claims processing.

Information Needed to Complete the CMS-1500 Name of insured’s insurance company Insured’s name Insured’s ID# Insured’s address Telephone # of insured 3

Reading the CMS-1500 Boxes (Blocks) 1-13: Boxes (Blocks) 14-33: Patient data Boxes (Blocks) 14-33: Provider information Information on services provided to patient Reason for services 4

CMS-1500: Boxes 1-3 Box 1: “X” used to indicate type of plan. Patient’s insurance ID# found on insurance card. Box 2: Patient’s name. Name must be entered as stated (Last name, First name, Middle initial). Box 3: Patient’s birth date and gender. Birth date must be 8-digits with use of zeros when needed. 5

CMS-1500: Boxes 4-6 Box 4: Insured’s name entered as directed. May be different or the same as the patient’s name. Word “same” is used if patient is the insured. Box 5: Patient’s address and telephone number entered accurately and completely. Box 6: “X” used to indicate patient’s relationship to the insured. 6

CMS-1500: Boxes 7-8 Box 7: Insured’s complete address and telephone number. Can leave blank if “same” has been written in Box #4. Box 8: “X” used to indicate marital and employment status. 7

Completion of the CMS-1500: Boxes 1-8

CMS-1500: Boxes 9-10 Box 9: Insured’s name entered as directed. Insured’s policy or group number. This is found on the insurance card. Insured’s 8-digit birth date and gender. Insured’s employer’s name or school. Insured's insurance plan/program name. Box 10: “Yes” or “No” used to indicate if patient’s condition is related to situations mentioned. 10d - always leave blank. 9

CMS-1500: Box 11 Box 11: Insured’s policy group or FECA number. Insured’s 8-digit date of birth and gender. Insured’s employment or school name. Insured’s insurance plan/program name. “X” placed in either YES or NO box to indicate if insurer carries another insurance policy. If 11d is checked YES than 9a-9d must be completed. 10

CMS-1500: Boxes 12-13 Box 12: Signature of patient or authorized person indicating that information can be released. SIGNATURE ON FILE may be used. Box 13: Necessary to have signed for payment to be dispersed to the provider. SIGNATURE ON FILE may be used. 11

Completion of the CMS-1500: Boxes 9-13 12

CMS-1500: Boxes 14-16 Box 14: Date of when the illness initially started, when the accident occurred, or date of last menstrual period (for pregnant women). Box 15: Dates of when patient has had same or similar condition. Box 16: If patient has been unable to work the 8-digit From and To dates. 13

CMS-1500: Boxes 17-19 Box 17: Name of referring physician or other source. I.D. number of referring physician. Box 18: Hospitalization that is related to current services. Must be entered as 8-digit from and to dates. Box 19: Leave blank. Reserved for local use. 14

CMS-1500: Boxes 20-21 Box 20: Indicates if an outside laboratory was used. Place a YES or No in box along with charges. Box 21: ICD-9-CM code for diagnosis or related to current condition. Codes must be listed in priority order. 15

CMS-1500: Boxes 22-23 Box 22: Medicaid resubmission code and original reference number. Box 23: Prior authorization number. 16

Completion of the CMS-1500: Boxes 14-23 17

CMS-1500: Box 24 Box 24: 24A – 8-digit date of when services for present condition have been received. 24B – Place of service 2 digit code. 24C – Leave blank. 24D – CPT/HCPCS code and modifier. 24E – Diagnosis code. 24F – Charges for service. 24G – Number of days or units of service. 24H-24j – Leave blank. 18

Completion of the CMS-1500: Box 24 A-J 19

CMS-1500: Boxes 25-27 Box 25: Physician’s Federal Tax I.D. number or Social Security Number. Box 26: Patient’s account number. Box 27: Indicates if physician accepts assignment. Check YES or NO. 20

CMS-1500: Boxes 28-31 Box 28: Total amount of charges. Box 29: Signature of provider of care with credentials. Box 29: Total amount so far paid. Box 30: Balance of bill. 21

CMS-1500: Boxes 32-33 Box 32: Name and address of where services were provided. Box 33: Supplier’s billing name, address, zip code, and telephone number. 22

Completion of the CMS-1500: Boxes 25-33 23

Prior to Submitting a Claim Check for accuracy on the claim form If a paper claim, make a copy for the patient’s file Enter data on the insurance claims log Send the completed CMS-1500 with required documentation to the insurance carrier 24

Confidentiality and the CMS-1500 As with all patient data, information must remain confidential Release of information must be signed by the patient Signed standard release form may be used Form is placed in patient file 25

Signature and Payment of Benefits Box 12: Patient signature indicates permission for releasing information on the claim form Box 13: If signed by patient, payment will go directly to service provider If not signed, payment is sent to the insured SIGNATURE ON FILE can also be used for this box 26

Assignment of Benefits Allowed by Medicare and other carriers One time form signed by patient Provides authorization for patient information to be released Once signed, usage of SIGNATURE ON FILE can be used Form must be permanently kept in the patient’s record 27

Participating Providers Physicians or medical facilities who choose to join an insurance company due to incentives offered by carrier Providers accept the insurance carrier’s set dollar amounts for services rendered Payments are made directly to providers Providers join by completing a form and being assigned a number 28

Participating vs. Nonparticipating Providers Advantage: Payment sent directly to the practice, typically in a timely manner Disadvantage: Reimbursement might be at a less desirable rate leading to write-offs 29

Materials Needed to Complete the CMS-1500 Patient’s medical record Patient’s ledger card Superbill CMS-1500 Black ink pen Computer with a printer or typewriter 30

The Superbill Contains: Patient’s name Diagnoses Treatments Space for claim information 31

The Superbill Usage: Originally created to allow patients to file own claims Accepted by some insurance companies as the claim form Provides detailed information on services received 32

The Birthday Rule Used to determine which parent’s insurance plan is primary Only used for parents who are legally married Primary plan is the one held by the parent whose birthday falls first in the year If parents have birthday on the same day, parent who has had the coverage the longest would hold the primary plan Primary plan of divorced parents is determined by court 33

Prior to Submitting a Claim Check for accuracy on the claim form If a paper claim, make a copy for patient’s file Enter data on the insurance claims log Send the completed CMS-1500 with required documentation to the insurance carrier 34

Questions? 35