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

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

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

2 Introduction to Health Care Claims HIPAA X12 837 Health Care Claim or Equivalent Form – HIPAA-mandated electronic transaction – Often called “837 claim” or “HIPAA claim” – CMS-1500 is the paper version Can only use if less than 10 full time employees and no electronic transactions – Payers may NOT require providers to make changes or additions to the 837 claim form Payers MAY, however, dictate how the form is filled out – National Uniform Claim Committee... NUCC Determines the content of the 2 claim forms and provides updates 2OT 232 Ch 8 lecture 1

3 Completing the CMS-1500 Claim Carrier block – For name and address of payer Blank 3 rd line if not needed No punctuation except for 9 digit zip Patient Information – Identifies the patient, the insured, the health plan, etc. – IN 1 – Type of Insurance “Group Health Plan” is not a company or plan name, but means the patient has a ‘group’ policy through an employer, etc., as opposed to an individual or government plan “Other” is marked if the patient has an individual commercial plan, is a member of an HMO, or the claim is for an automobile accident, liability or worker’s comp. 3OT 232 Ch 8 lecture 1

4 Completing the CMS-1500 Claim (cont’d) – IN 1a ID number that appears on the insurance card of the person who holds the policy – IN 2 Patient’s name – Not always the same as 1a – EXACTLY as it appears on insurance card – IN 3 Patient’s DOB & Gender – Enter all 4 digits for year despite “YY” on form – IN 4 Insured’s Name – Full name of person who holds policy – Follow instructions!! Some policies require the word “same” in the box if the insured is also the patient, others want it left blank 4OT 232 Ch 8 lecture 1

5 Completing the CMS-1500 Claim (cont’d) – IN 5 Patient’s address – Use permanent address – IN 6 Patient’s relationship to insured – Child » Minor defined by policy – Other » Employee, ward – check policy – IN 7 Insured’s address – In most cases, ‘same’ can be entered – IN 8 Patient’s status – Important for determination of liability and coordination of benefits 5OT 232 Ch 8 lecture 1

6 Completing the CMS-1500 Claim (cont’d) – INs 9 through 9d Only used if there is a secondary policy that covers the patient – Leave blank if none – INs 10a through c Patient Condition Related to… – An ‘x’ is going to indicate that another insurance may be primary over the patient’s – IN 10d Reserved for Local Use – Varies by plan – Commonly used to indicate “Attachments” – IN 11 Insured’s Policy Group or FECA number – Federal Employees’ Compensation Act 6OT 232 Ch 8 lecture 1

7 Completing the CMS-1500 Claim (cont’d) – INs 11a through c To be filled in if the insured is different than the patient – IN 11d Indicates a secondary policy – If ‘yes’, then 9 should be filled out! – IN 12 Patient’s or Authorized Person’s Signature For TPO – IN 13 Insured or Authorized Person’s Signature 7OT 232 Ch 8 lecture 1

8 Completing the CMS-1500 Claim (cont’d) Physician or Supplier Information – Identifies provider, describes services performed, etc. – IN 14 Date of Current Illness or Injury or Pregnancy – Date illness began, of injury, or last menstrual period (LMP) – IN 15 If Patient Has Had Same or Similar Illness – Often left blank – Previous child is NOT a similar illness! – IN 16 Dates Patient Unable to Work in Current Occupation – May indicate employment-related insurance coverage 8OT 232 Ch 8 lecture 1

9 Completing the CMS-1500 Claim (cont’d) – IN 17 Name of Referring Physician or Other Source – INs 17a & b ID Number of Referring Physician (split field) – 17a » Non-NPI (‘other ID’ number) Qualifier 2 digit indicating what the number represents Table 8.1, page 252 Number itself – 17b » NPI number HIPAA National Provider Identifier – IN 18 Hospitalization Dates Related to Current Services 9OT 232 Ch 8 lecture 1

10 Completing the CMS-1500 Claim (cont’d) – IN 19 Reserved for Local Use – Another ‘flex’ box; check with payer for instructions – IN 20 Outside Lab? $Charges – ‘yes’ if service was outsourced and now want to bill patient – Entering the amount is tricky! » Enter the amount right-aligned to the vertical line with no decimal or $. Use 00 if no cents. $576.00 = 57600 – Can only bill for one outside service on each claim 10OT 232 Ch 8 lecture 1

11 Completing the CMS-1500 Claim (cont’d) – IN 21 Diagnosis – List ICD9 codes DIRECTLY RELATED TO THE PROCEDURES BEING BILLED FOR – Enter the primary diagnosis first – Can list up to 4 » If +4, will have to split the claim with some procedures & diagnoses on another – IN 22 Medicaid Resubmission – Left blank on all claims EXCEPT for Medicaid plans – Only to be used when resubmitting a claim or encounter 11OT 232 Ch 8 lecture 1

12 Completing the CMS-1500 Claim (cont’d) – IN 23 Prior Authorization Number – Used to enter the payer’s authorization number for procedures and diagnostic tests that require preauthorization – Section 24 Service Line Information – Only 6 lines to bill for » Top, shaded part is for additional info – IN 24A Dates of Service – If just one day, use the FROM box – If you want to ‘group’ charges for several days, everything on the line – procedure, PoS, charges & providers – must be identical and the services must have been performed on consecutive days – IN24B Place of Service Appendix B, page 637 12OT 232 Ch 8 lecture 1

13 Completing the CMS-1500 Claim (cont’d) – IN 24C Some payers require a “Y” for ‘emergency situations (severe, life-threatening, potentially disabling, etc.) Leave blank if no – Book says enter “N”, but NUCC… » National Uniform Claim Committee – …says to leave blank This is not related to an emergency room visit, which would be POS 23 – IN 24D Procedures, Services or Suppliers – Procedure code in effect on the date of service 13OT 232 Ch 8 lecture 1

14 Completing the CMS-1500 Claim (cont’d) – IN 24E Diagnosis Pointer – Is the connection between the diagnosis and the treatment » Get info from IN 21 – IN 24F $ Charges – Total billed charges for the service » If no charge… Capitated or global » …enter 00 » If for multiple units, enter total charge – IN 24G Days or Units – If days, reference 24A – In 24H EPSDT Family Plan – Used for referral codes in some Medicaid plans 14OT 232 Ch 8 lecture 1

15 Completing the CMS-1500 Claim (cont’d) – INs 24I & J ID for the rendering doctor IF it is not the same as the provider – If NPI, enter in 24J and leave 24I blank – If not an NPI, (remember 17a & b?) the qualifier goes in 24I and the corresponding id number in 24J – IN 25 Federal Tax ID Number – Physician or supplier – IN 26 Patient’s Account Number – One given to patient by provider – IN 27 ‘Yes’ if provider agrees to take allowed amount as payment in full and NOT balance bill 15OT 232 Ch 8 lecture 1

16 Completing the CMS-1500 Claim (cont’d) – IN 28 Total of all charges on claim – No dollar signs or commas – If 2 pages, note ‘continued’ – IN 29 Amount paid by patient for covered services – copay or toward deductible Amount received from primary insurance – IN 30 Balance bill – IN 30 Signature of Physician or Supplier w/Degrees or Credentials – Can use “SOF” 16OT 232 Ch 8 lecture 1

17 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 262-3 17OT 232 Ch 8 lecture 1

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