Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 07 The Paper Claim CMS-1500 (02-12) Insurance Handbook for the Medical Office 13 th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Background and Submission of CMS-1500 (02-12) 1. Identify the circumstances in which paper claims continue to be used. 2. Discuss the history of the Health Insurance Claim Form (CMS-1500 [02-12]). 3. Define two types of claims submission. 4. Explain the difference between clean, pending, rejected, incomplete, and invalid claims. 2 Lesson 7.1

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Background and Submission of CMS-1500 (02-12) (cont’d) 5. List the elements typically abstracted from the medical record that are included in a cover letter accompanying an insurance claim. 6. Describe basic guidelines for submitting insurance claims. 7. Explain how the diagnostic field of the CMS-1500 (02-12) claim form would be completed. 8. Explain the difference between PIN, UPIN, and NPI numbers. 3 Lesson 7.1

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Background and Submission of CMS-1500 (02-12) (cont’d) 9. Discuss the importance of proofreading every paper claim. 10. Describe reasons why claims are rejected. 11. Identify claim submission errors, and discuss the solution to correct the error. 12. Identify techniques required for submission of claims. 4 Lesson 7.1

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved The Paper Claim CMS-1500 (02-12)  Administrative Simplification Compliance Act (ASCA)  All claims submitted electronically to Medicare  Some exceptions Small providers Disruption of electricity/communication connections Any other health plan Technical downtime Reporting special services Resubmitting a claim Practice is non-participating Report patient encounter data 5

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved History of the Paper Claim CMS  Standard form created in 1958  AMA approved a “universal claim form” in 1975  Originally called Health Insurance Claim Form (HCFA- 1500)  Recently called CMS-1500 (08-05)  Now called CMS-1500 (02-12)  Revised form made available for optical scanning in 1990  Revised form for NPI inclusion made available in 2005  CMS-1500 (08-05) will no longer be accepted after October 1,

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Types of Submitted Claims  Paper claim  Submitted on paper or optically scanned  Typed or computer-generated  Electronic claim  Submitted via electronic method  Digital file not printed on paper 7

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Status  Clean claim: claim was submitted within the program or policy time limit and contains all necessary information  Physically clean claim: has no staples or highlighted areas, bar code area has not been deformed  Rejected claim: not processed or cannot be processed  Pending claim: held in suspense because of review or other reason 8

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicare Claim Status  Incomplete claim: missing required information  Invalid claim: contains complete, necessary information but is illogical or incorrect  Dirty claim: submitted with errors, requiring manual processing for resolution, or rejected for payment  Deleted claim: canceled, deleted, or voided by a Medicare fiscal intermediary 9

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Abstracting from Medical Records  Reasons for abstracting from medical records  To complete insurance claim forms  When sending a letter to justify a health insurance claim after professional services are rendered  When a patient applies for life, mortgage, or health insurance 10

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Basic Guidelines for Submitting a Claim  Individual insurance  Group insurance  Secondary insurance 11

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Completion of Insurance Claim Forms  Diagnosis  Block 21  Primary diagnosis code listed first, followed by any secondary diagnosis codes CMS-1500 (02-12) can report up to 12 diagnostic codes  Diagnosis should never be submitted without supporting documentation in medical record 12

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Completion of Insurance Claim Forms  Service dates  Consecutive dates  No charge 13

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Completion of Insurance Claim Forms  Physicians’ identification numbers  State license number  Employer identification number (EIN)  Social Security number (SSN)  National Provider Identifier (NPI)  Provider identification number (PIN)  Unique physician identification number (UPIN)  Group National Provider Identifier (group NPI)  Durable medical equipment (DME) number  Facility provider number  Taxonomy code 14

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Completion of Insurance Claim Forms  Physician’s signature  Insurance biller’s initials  Proofread  Supporting documentation  Office pending file 15

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Common Reasons Why Claim forms are Delayed or Rejected  Claim submitted to the secondary insurer instead of the primary insurer.  Information missing on patient portion of the claim form.  Patient’s insurance number is incorrect or transposed.  Patient’s name and insured’s name are entered as the same when the patient is a dependent.  Failure to indicate whether patient’s condition is related to employment or an “other” type of accident.  Patient’s signature is missing.  Physician’s signature is missing. 16

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Do’s and Don’ts for Claim Completion  DO: Use original claim forms printed in red ink  DO: Alight printer correctly  DO: Keep characters within border of each field  DO: Complete new form for additional services  DO: Enter 6-digit or 8-digit date formats  DO: Keep signature within signature block  DO: Enter information via computer keyboard 17

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Do’s and Don’ts for Claim Completion  DON’T: Handwrite information on document  DON’T: Allow characters to touch lines.  DON’T: Use specialized characters and fonts  DON’T: Strike over errors 18

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Do’s and Don’ts for Claim Completion  DON’T: Use highlighter pens or colored in  DON’T: Use decimals in Block 21 or dollar signs in money column.  DON’T: Use N/A or DNA when information not applicable  DON’T: Use paper clips, cellophane tape, stickers, rubber stamps, or staples  DON’T: Fold or spindle forms when mailing 19

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Practice CMS-1500 (02-12) Submission 13. Demonstrate the ability to complete the CMS-1500 (02-12) claim form accurately for federal, state, and private payer insurance contracts using current basic guidelines. 20 Lesson 7.2

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Carrier Block  Block 1: Medicare, Medicaid, TRICARE, CHAMPVA, Group Health Plan, FECA, Black Lung, Other  Block 1a: Insured’s ID Number  Block 2: Patient’s Name  Block 3: Patient’s Birth Date, Sex  Block 4: Insured’s Name 21

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 5: Patient’s Address  Block 6: Patient Relationship to Insured  Block 7: Insured’s Address  Block 8: Reserved for NUCC Use 22

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 9: Other Insured’s Name  Block 9a: Other Insured’s Policy or Group Number  Block 9b: Reserved for NUCC Use  Block 9c: Reserved for NUCC Use  Block 9d: Insurance Plan Name or Program Name 23

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Blocks 10a-10c: Is Patient’s Condition Related to  Block 10d: Claim Codes 24

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 11: Insured’s Policy, Group, or FECA Number  Block 11a: Insured’s Date of Birth, Sex  Block 11b: Other Claim ID (Designated by NUCC)  Block 11c: Insurance Plan Name or Program Name  Block 11d: Is there another Health Benefit Plan? 25

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 13: Insured’s or Authorized Person’s Signature  Block 14: Date of Current Illness, Injury, or Pregnancy (LMP)  Block 15: Other Date  Block 16: Dates Patient Unable to Work in Current Occupation 26

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 17: Name of Referring Provider or Other Source  Block 17a: Other ID Number  Block 17b: NPI  Block 18: Hospitalization Dates Related to Current Services  Block 19: Additional Claim Information (Designated by NUCC) 27

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 20: Outside Lab Charges  Block 21: Diagnosis of Nature of Illness or Injury  Block 22: Resubmission and/or Original Reference Number  Block 23: Prior Authorization Number 28

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 24A: Date(s) of Service (Lines 1-6)  Block 24B: Place of Service (Lines 1-6)  Block 24C: EMG (Lines 1-6)  Block 24D: Procedures, Services, or Supplies (Lines 1-6) 29

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 24E: Diagnosis Pointer (Lines 1-6)  Block 24F: Charges (Lines 1-6)  Block 24G: Days or Units (Lines 1-6)  Block 24H: EPSDT/Family Plan (Lines 1-6) 30

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 24I: ID Qualifier (Lines 1-6)  Block 24J: Rendering Provider ID # (Lines 1- 6)  Instructions and examples of supplemental information in Item Number 24 31

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 25: Federal Tax ID Number  Block 26: Patient’s Account No.  Block 27: Accept Assignment?  Block 28: Total Charge 32

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 29: Amount Paid  Block 30: Reserved for NUCC Use  Block 31: Signature of Physician or Supplied Including Degrees or Credentials  Block 32: Service Facility Location Information  Block 32a: NPI#  Block 32b: Other ID# 33

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Block-By-Block Instructions for Completion of the CMS-1500 (02-12)  Block 33: Billing Provider Info & Ph#  Block 33a: NPI#  Block 33b: Other ID# 34

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Insurance Program Templates  Private payer  Medicaid  Medicare  Medicaid/Medigap – a crossover claim  Medicare/Medigap – a crossover claim 35

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Insurance Program Templates  MSP – other insurance primary and Medicare secondary  TRICARE – standard  CHAMPVA  Workers’ compensation 36

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 37