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© 2017 Cengage Learning® . May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved. CHAPTER 11 Essential CMS-1500 Claim Instructions ASSIGNMENT 11.1 National Provider Identifier (NPI) Standard 1. a. The EFI is also known as the bulk enumeration. EFI is a process where a provider or group can have an organization apply for their NPI. b. The EFI process is designed to allow provider-designated organizations (the EFIOs) to capture multiple providers’ NPI application information on a single electronic file for submission to NPPES. To explain, administrative simplification provisions of HIPAA required adoption of a standard unique identifier for all health care providers for use in the nationwide health care system. The NPI is the standard identifier providers began applying for NPIs in 2005. Since all HIPAA-covered entities, including Medicare and all other health plans, must report NPIs in HIPAA standard transactions (including electronic claims), providers must obtain NPIs promptly so they can use them in these transactions and not experience interruptions or delays in receiving reimbursement from a health plan. A provider can currently obtain an NPI via a paper application or over the web through the National Plan and Provider Enumeration System (NPPES). Applications must be submitted individually, on a per-provider basis. 2. a. The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique (10-character) identification number for covered health care providers. b. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. ASSIGNMENT 11.2 Medically Unlikely Edits (MUE) Project 1. CMS developed medically unlikely edits (MUEs) to reduce the paid claims error rate for Part B claims. 2. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. 3. The MUE was implemented January 1, 2007, and is utilized to adjudicate claims at Carriers, Fiscal Intermediaries, and DME MACs. 4. Inquiries about a specific claim should be addressed to the claims processing contractor. 5. Inquiries about the rationale for an MUE value should be addressed to your claims processing contractor or a national health care organization whose members often perform the procedure. CHAPTER 11: Essential CMS-1500 Claim Instructions 165 NOTE: The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identifi- cation numbers and other information, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways. NOTE: HIPAA requires that covered entities (e.g., health plans, health care clearinghouses, and those health care providers who transmit any health information in electronic form in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions by the compliance dates. The compliance date for all covered entities except small health plans was May 23, 2007; the compliance date for small health plans was May 23, 2008. As of the compliance dates, the NPI is the only health care provider identifier that can be used for identification purposes in standard transactions by covered entities.

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Page 1: CHAPTER 11 Essential CMS-1500 Claim Instructions

© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.

CHAPTER 11 Essential CMS-1500 Claim Instructions

ASSIGNMENT 11.1 National Provider Identifier (NPI) Standard 1. a. The EFI is also known as the bulk enumeration. EFI is a process where a provider or group

canhaveanorganizationapplyfortheirNPI. b. The EFI process is designed to allow provider-designated organizations (the EFIOs) to capture

multipleproviders’NPIapplicationinformationonasingleelectronicfileforsubmissiontoNPPES.Toexplain,administrativesimplificationprovisionsofHIPAArequiredadoptionofastandard unique identifier for all health care providers for use in the nationwide health care system.TheNPIisthestandardidentifierprovidersbeganapplyingforNPIsin2005.SinceallHIPAA-coveredentities,includingMedicareandallotherhealthplans,mustreportNPIsinHIPAAstandardtransactions(includingelectronicclaims),providersmustobtainNPIspromptly so they can use them in these transactions and not experience interruptions or delaysinreceivingreimbursementfromahealthplan.AprovidercancurrentlyobtainanNPIviaapaperapplicationoroverthewebthroughtheNationalPlanandProviderEnumerationSystem(NPPES).Applicationsmustbesubmittedindividually,onaper-providerbasis.

2. a.TheNationalProviderIdentifier(NPI)isaHealthInsurancePortabilityandAccountability Act(HIPAA)AdministrativeSimplificationStandard.TheNPIisaunique(10-character)

identification number for covered health care providers.

b. Covered health care providers and all health plans and health care clearinghouses must usetheNPIsintheadministrativeandfinancialtransactionsadoptedunderHIPAA.

ASSIGNMENT 11.2 Medically unlikely Edits (MuE) Project 1.CMSdevelopedmedicallyunlikelyedits(MUEs)toreducethepaidclaimserrorrateforPartB

claims.

2.AnMUEforaHCPCS/CPTcodeisthemaximumunitsofservicethataproviderwouldreportunder most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codesdonothaveanMUE.

3. TheMUEwasimplementedJanuary1,2007,andisutilizedtoadjudicateclaimsatCarriers,FiscalIntermediaries,andDMEMACs.

4. Inquiries about a specific claim should be addressed to the claims processing contractor.

5.InquiriesabouttherationaleforanMUEvalueshouldbeaddressedtoyourclaims processing contractor or a national health care organization whose members often perform

the procedure.

ChApTEr 11: Essential CMS-1500 Claim Instructions 165

NOTE: ThepurposeoftheNationalProviderIdentifier(NPI)istouniquelyidentifyahealthcareproviderinstandardtransactions,suchashealthcareclaims.NPIsmayalsobeusedtoidentifyhealthcareprovidersonprescriptions,ininternalfilestolinkproprietaryprovideridentifi-cationnumbersandotherinformation,incoordinationofbenefitsbetweenhealthplans,inpatientmedicalrecordsystems,inprogramintegrityfiles,andinotherways.

NOTE: HIPAArequiresthatcoveredentities(e.g.,healthplans,healthcareclearinghouses,andthosehealthcareproviderswhotransmitanyhealthinformationinelectronicforminconnectionwithatransactionforwhichtheSecretaryofHealthandHumanServiceshasadoptedastandard)useNPIsinstandardtransactionsbythecompliancedates.ThecompliancedateforallcoveredentitiesexceptsmallhealthplanswasMay23,2007;thecompliancedateforsmallhealthplanswasMay23,2008.Asofthecompliancedates,theNPIistheonlyhealthcareprovideridentifierthatcanbeusedforidentificationpurposesinstandardtransactionsbycoveredentities.

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Page 2: CHAPTER 11 Essential CMS-1500 Claim Instructions

166 SECTION V: Answer Keys to Workbook Chapter Assignments

ASSIGNMENT 11.3 Identifying CMS-1500 Claims Completion Errors

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Page 3: CHAPTER 11 Essential CMS-1500 Claim Instructions

ChApTEr 11: Essential CMS-1500 Claim Instructions 167

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47442_sec05_ptg01.indd 167 24/11/15 10:06 PM

Page 4: CHAPTER 11 Essential CMS-1500 Claim Instructions

168 SECTION V: Answer Keys to Workbook Chapter Assignments

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47442_sec05_ptg01.indd 168 24/11/15 10:06 PM

Page 5: CHAPTER 11 Essential CMS-1500 Claim Instructions

ChApTEr 11: Essential CMS-1500 Claim Instructions 169

© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.

ASSIGNMENT 11.4 Multiple Choice Review 1. d 9. d 2. b 10. b 3. c 11. c 4. b 12. b 5. b 13. c 6. b 14. d 7. d 15. b 8. a

47442_sec05_ptg01.indd 169 24/11/15 10:06 PM


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