Download presentation
Presentation is loading. Please wait.
Published byClaude Chapman Modified over 8 years ago
1
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
2
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
3
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
4
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
5
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
6
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved History of the Paper Claim CMS- 1500 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, 2013 6
7
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
8
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
9
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
10
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
11
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
12
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
13
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Completion of Insurance Claim Forms Service dates Consecutive dates No charge 13
14
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
15
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
16
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
17
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
18
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
19
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
20
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
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) 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
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 5: Patient’s Address Block 6: Patient Relationship to Insured Block 7: Insured’s Address Block 8: Reserved for NUCC Use 22
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) 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
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) Blocks 10a-10c: Is Patient’s Condition Related to Block 10d: Claim Codes 24
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 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
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 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
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 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
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 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
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 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
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 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
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 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
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 25: Federal Tax ID Number Block 26: Patient’s Account No. Block 27: Accept Assignment? Block 28: Total Charge 32
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 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
34
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
35
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
36
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
37
Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 37
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.