Download - Chapter 07 The Paper Claim CMS-1500 (02-12)
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
13th 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.
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Lesson 7.1
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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.
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Lesson 7.1
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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.
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Lesson 7.1
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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
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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
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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
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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
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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
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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
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Basic Guidelines for Submitting a Claim
Individual insurance Group insurance Secondary insurance
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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
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Completion of Insurance Claim Forms
Service dates Consecutive dates No charge
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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
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Completion of Insurance Claim Forms
Physician’s signature Insurance biller’s initials Proofread Supporting documentation Office pending file
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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.
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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
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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
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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
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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.
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Lesson 7.2
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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
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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
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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
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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
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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?
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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
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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)
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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
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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)
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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)
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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
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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
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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#
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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#
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Insurance Program Templates
Private payer Medicaid Medicare Medicaid/Medigap – a crossover claim Medicare/Medigap – a crossover claim
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Insurance Program Templates
MSP – other insurance primary and Medicare secondary
TRICARE – standard CHAMPVA Workers’ compensation
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Questions?
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