11 Physician Medical Billing

Key Terms and Abbreviations assignment of benefits form audit/edit report billing services birthday rule claim attachment clean claims clearinghouse CMS-1500 claim form

Key Terms and Abbreviations coordination of benefits (COB) dirty claim durable medical equipment (DME) number electronic claims, electronic media claims (EMCs) encryption employer identification number (EIN)

Key Terms and Abbreviations facility provider number (FPN) form locators group provider number (GPN) guarantor National Provider Identifier (NPI) number optical character recognition (OCR) patient information form

Key Terms and Abbreviations policyholder provider identification number (PIN) release of information form secondary insurance state license number superbills supplemental insurance tax identification number (TIN)

Key Terms and Abbreviations UB-04 claim form verification of benefits (VOB) form

Chapter Objectives After completing this lecture, you should be able to complete the following learning objectives: 11.1: Differentiate and complete medical claim forms accurately, both manually and electronically. 11.2: Define claim form parts, sections, and required information.

Chapter Objectives After completing this lecture, you should be able to complete the following learning objectives: 11.3: Exhibit the ability to complete claim forms without omitting information. 11.4: Understand the common reasons why claim forms are delayed or rejected and submit a claim without payer rejection.

Chapter Objectives After completing this lecture, you should be able to complete the following learning objectives: 11.5: File a secondary claim.

Manual and Electronic Medical Claim Forms 11.1: Differentiate and complete medical claim forms accurately, both manually and electronically.

11.1: Manual and Electronic Medical Claim Forms Insurance Claims A claim is also called an encounter record. Insurance claims can be submitted to payers in paper format (manually) or electronically.

11.1: Manual and Electronic Medical Claim Forms Insurance Claims Electronic claims, also known as electronic media claims (EMCs), are submitted through a clearinghouse, billing service, or directly to the carrier. These contain electronic signatures.

11.1: Manual and Electronic Medical Claim Forms Insurance Claims Advantages of electronic claim submission include lower administrative costs, reduced claim rejection, and faster payment.

11.1: Manual and Electronic Medical Claim Forms CMS-1500 Claim Form The CMS-1500 Health Insurance Claim Form was developed by the Centers for Medicare and Medicaid Services. The CMS-1500 is mandatory for Medicare claims and has become the standard claim form used by private and government payers.

11.1: Manual and Electronic Medical Claim Forms CMS-1500 Claim Form The paper CMS-1500 form is printed in red ink to be recognizable to optical character recognition (OCR) scanners.

11.1: Manual and Electronic Medical Claim Forms Completion of Claim Forms Specific guidelines exist for accurately completing the CMS-1500 form. Government programs (Medicare, Medicaid, TRICARE, CHAMPVA, and workers’ compensation) have claim submission rules specific to their program.

11.1: Manual and Electronic Medical Claim Forms Completion of Claim Forms State insurance regulations and local guidelines also vary, so the medical office specialist must be familiar with federal, state, and local rules as well as with guidelines from private insurance carriers and government programs.

11.1: Manual and Electronic Medical Claim Forms Completion of Claim Forms Claim attachments are additional documentation sent to a payer to substantiate the medical necessity of a claim.

11.2: Define claim form parts, sections, and required information. Claim Forms 11.2: Define claim form parts, sections, and required information.

11.2: Claim Forms Parts of the CMS-1500 Claim Form In this textbook, each numbered field or item to be completed on the CMS-1500 is called a form locator. The upper portion of the form contains patient and insured information. It consists of 13 form locators (numbered 1–13) with 11 data elements and 2 signature fields.

11.2: Claim Forms Parts of the CMS-1500 Claim Form The lower portion of the form contains physician or supplier information. It consists of 20 form locators (numbered 14–33) with 19 data elements and 1 signature field.

Figure 11.10a -- CMS-1500 claim form 11.2: Claim Forms Figure 11.10a -- CMS-1500 claim form

Figure 11.10a -- CMS-1500 claim form 11.2: Claim Forms Figure 11.10a -- CMS-1500 claim form

Figure 11.10a -- CMS-1500 claim form 11.2: Claim Forms Figure 11.10a -- CMS-1500 claim form

Figure 11.10b -- Draft CMS-1500 form, version 02/12. 11.2: Claim Forms Figure 11.10b -- Draft CMS-1500 form, version 02/12.

Figure 11.10b -- Draft CMS-1500 form, version 02/12. 11.2: Claim Forms Figure 11.10b -- Draft CMS-1500 form, version 02/12.

Table 11.1 -- CMS-1500 Abbreviations> 11.2: Claim Forms Table 11.1 -- CMS-1500 Abbreviations>

Table 11.1 -- CMS-1500 Abbreviations> 11.2: Claim Forms Table 11.1 -- CMS-1500 Abbreviations>

Completed Claim Form 11.3: Exhibit the ability to complete claim forms without omitting information.

Figure 11.11 -- Practice Exercise 11.1 CMS-1500 form. 11.3: Completed Claim Form Figure 11.11 -- Practice Exercise 11.1 CMS-1500 form.

11.3: Completed Claim Form CMS-1500 Required Information 1 Type of Insurance Type of government or private insurance. 1a Insured ID Number ID number as shown on the insurance card.

11.3: Completed Claim Form CMS-1500 Required Information 2 Patient’s Name Must match name shown on the insurance card. 3 Patient’s Date of Birth/Sex Enter date and check correct box.

11.3: Completed Claim Form CMS-1500 Required Information 4 Insured’s Name If patient is the insured, enter “Same.” 5 Patient’s Address Enter complete address. 6 Patient’s Relationship to the Insured Check correct box.

11.3: Completed Claim Form CMS-1500 Required Information 7 Insured’s Address If patient is the insured, leave blank. 8 Patient Status Check correct box for marital and employment status.

11.3: Completed Claim Form CMS-1500 Required Information 9 Other Insured’s Name Enter name if there is a holder of another policy that may cover the patient. If no secondary policy applies, leave blank.

11.3: Completed Claim Form CMS-1500 Required Information 9a Other Insured’s Policy or Group Number If a secondary policy applies, enter the number as it appears on the insurance card.

11.3: Completed Claim Form CMS-1500 Required Information 9b Other Insured’s Date of Birth/Sex 9c Employer’s Name or School Name (for insured) 9d Insurance Plan Name or Program Name Enter name of secondary insurance plan.

11.3: Completed Claim Form CMS-1500 Required Information 10a/b/c Is Patient’s Condition Related to: Check correct box. 10d Reserved for Local Use Use this per specific carrier guidelines. 11 Insured’s Policy Group or FECA Number Enter group number as it appears on the insurance card.

11.3: Completed Claim Form CMS-1500 Required Information 11a Insured’s Date of Birth/Sex 11b Employer’s Name or School Name (for insured) 11c Insurance Plan Name or Program Name (for primary plan) 11d Is There Another Health Benefit Plan? Check correct box.

11.3: Completed Claim Form CMS-1500 Required Information 12 Patient or Authorized Person’s Signature

11.3: Completed Claim Form CMS-1500 Required Information 13 Insured’s or Authorized Person’s Signature Signature of patient or insured authorizes direct payment to the provider or supplier. 14 Date of Current Illness, Injury, Pregnancy

11.3: Completed Claim Form CMS-1500 Required Information 15 If Patient Has Had Same or Similar Illness Enter first date of treatment for same/similar illness. 16 Dates Patient Unable to Work in Current Occupation

11.3: Completed Claim Form CMS-1500 Required Information 17 Name of Referring Physician or Other Source Enter physician first and last name and credentials; leave blank if no referring physician. 

11.3: Completed Claim Form CMS-1500 Required Information 17a ID Number of Referring Physician Enter ID number and two-character qualifier. 17b NPI Number Enter NPI number of referring physician.

11.3: Completed Claim Form CMS-1500 Required Information 18 Hospitalization Dates Related to Current Services 19 Reserved for Local Use Use this per specific carrier guidelines. 20 Outside Lab Check correct box; if “Yes,” enter amount.

11.3: Completed Claim Form CMS-1500 Required Information 21 Diagnosis or Nature of Illness or Injury Enter ICD-9 or ICD-10 codes. 22 Medicaid Resubmission Code Use for Medicaid claims, if applicable. 23 Prior Authorization Number Use when required by the carrier.

11.3: Completed Claim Form CMS-1500 Required Information 24A Dates of Service  24B Place of Service Enter code for location. 24C EMG (Emergency) Enter Y for “Yes” if emergency service; leave blank for “No.” 

11.3: Completed Claim Form CMS-1500 Required Information 24D Procedures, Services, or Supplies Enter CPT or HCPCS codes and any necessary modifiers. 24E Diagnosis Pointer Indicates the number (1, 2, 3, and/or 4) of the diagnosis code shown in form locator 21.

11.3: Completed Claim Form CMS-1500 Required Information 24F Charges Enter amount for each CPT or HCPCS code. 24G Days or Units 24H EPSDT Family Plan Enter Y for “Yes” if services provided through Medicaid EPSDT (plus any required codes) or N for “No.”

11.3: Completed Claim Form CMS-1500 Required Information 24I ID Qualifier Enter qualifier for non-NPI number, if applicable. 24J Rendering Provider Enter non-NPI and NPI numbers. 25 Federal Tax ID Number

11.3: Completed Claim Form CMS-1500 Required Information 26 Patient’s Account Number Enter account number assigned by the medical facility. 27 Accept Assignment? Check correct box. 28 Total Charge Enter amount.

11.3: Completed Claim Form CMS-1500 Required Information 29 Amount Paid If amount was paid by a primary insurer, this is used in submitting a claim to a secondary insurer. 30 Balance Due Amount is total charge (form locator 28) less any amounts paid (form locator 29).

11.3: Completed Claim Form CMS-1500 Required Information 31 Signature of Physician or Supplier Including Degrees or Credentials Signature and date signed. May use “SOF” for “Signature on File.”

11.3: Completed Claim Form CMS-1500 Required Information 32 Name and Address of Facility Where Services Were Rendered 32a NPI Number 32b Other ID Number Enter non-NPI number and qualifier. 33 Billing Provider Info and Phone Number

11.3: Completed Claim Form CMS-1500 Required Information 33a NPI Number 33b Other ID Number Enter non-NPI number and qualifier.

Rejected Claims 11.4: Understand the common reasons why claim forms are delayed or rejected and submit a claim without payer rejection.

11.4: Rejected Claims Common Reasons for Delays or Rejections Claim submitted to secondary insurer instead of primary insurer Missing information on patient/insured portion of claim form Missing information on physician/supplier portion of claim form

11.4: Rejected Claims Common Reasons for Delays or Rejections Numbers are transposed Signatures are missing Incorrect gender ID shown so that diagnosis or procedure codes are not consistent with gender Dates entered in an inconsistent format

11.4: Rejected Claims Common Reasons for Delays or Rejections Missing or incorrect place of service Errors in diagnosis or procedure codes Itemized charges unequal to total amount shown

11.5: File a secondary claim.

11.5: Secondary Claim Types of Coverage Primary insurance: the first policy or plan to provide coverage, such as group plan through an employer Secondary insurance: additional policy or plan that covers an individual, such as coverage through a spouse’s plan

11.5: Secondary Claim Types of Coverage Supplemental insurance: limited coverage of partial expenses, such as Medigap policies

11.5: Secondary Claim Filing Secondary Claims Coordination of benefits (COB) occurs when a patient is covered by more than one policy or plan. With COB, the total benefits paid by all policies cannot exceed 100% of charges.

11.5: Secondary Claim Filing Secondary Claims Insurance carriers communicate with each other regarding payments and denials.

11.5: Secondary Claim Filing Secondary Claims Various standards are used to determine which policy is designated as primary coverage, including length of time in effect, employment or retiree status, dependant status, and other factors.

11.5: Secondary Claim Filing Secondary Claims A copy of the primary carrier’s EOB must be submitted with a secondary claim. Prior authorization and referral numbers may still be required for secondary claims.