1. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. The Health Insurance Claim Form Chapter 20

2. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Introduction Medical insurance means different things to different people: Mounds of paperwork Mass of confusion Constant change Lifesaving help for high medical expenses

3. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. This chapter will examine: Differences between paper claims and electronic claims Guidelines for completing the CMS-1500 form Completing each of the blocks of the CMS-1500 form Differences between clean and dirty claims Methods of preventing claim rejection Checking claim status

4. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Universal Claim Form CMS-1500 Claim Form Revised 08/05 Used for most claims submitted to insurance companies

5. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Types of Claims Hard copies – Physically printed and mailed to insurance companies Electronic claims – Submitted via electronic media

6. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Methods of Electronic Claims Submissions Direct billing – Transmitted directly to the insurance carrier Clearinghouses – Submits insurance claims to the carrier for the providers

7. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Advantages and Disadvantages of Electronic Billing

8. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Electronic Claims Processing Reduces the time required for reimbursement Can reduce error rates by 1% to 2% Shortens payment cycle

9. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. National Provider Identifier All allied health providers of service will be assigned one provider number. Uniform, national number replaces the many numbers used by the various providers. SSN, EIN, and TIN must still be used for tax and income reporting purposes.

10. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Data Gathering Guidelines Photocopy the insurance ID card, back and front. Obtain demographic information about the patient. Obtain information on both policies if the patient has more than one. Get information about the insured if he or she is different from the patient. Obtain needed signatures for permission to bill and accept payment directly from the insurance company.

11. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Verification of Eligibility and Benefits Call the insurance company to verify benefits. Obtain a general overview of covered items.

12. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Assignment of Insurance Benefits

13. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. CMS-1500 Health Insurance Claim Form Standardized form used by most insurance carriers. Recently revised slightly to include the NPI. The 08/05 version must be in use by all providers after April 1, 2007. Contains three sections – Address of carrier – Patient information – Provider information, including diagnosis and procedure codes

14. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Carrier Block

15. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Blocks 1 to 8

16. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Blocks 9 to 13

17. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Blocks 14 to 23

18. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Blocks 24 to 33

19. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Denied or Rejected Claims Always follow up on denied or rejected claims to discover if a simple fix is appropriate.

20. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Checking Claim Status Periodically check to see what claims have not been paid. Contact the carrier to determine the issue with the claim. Provide more information as needed. Continue follow-up efforts.

21. Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. Audit Trails Used to verify that information was submitted correctly Provide a record Locate sources of errors