Chapter 8 Claim Forms Flashcards
Claim Forms
s/p/s (my own term. it means service, procedure, supplies)
Are used to report the s/p/s and the reason the s/p were performed to the Ins Carrier to obtain payment.
Two claim forms.
CMS-1500 and (P837 electronic)
UB-04 claim forms
CMS-1500
to report professional services performed by providers and ASC Ambulatory Surgical Centers.
UB-04
To report facility services.
National Uniform Claim Committee
responsible for development and maintenance of CMS 1500 form.
CMS 1500 is public domain not subject to copyright.
NUCC represents interest of
*Providers
*Payers
*DSMO designated Standards Maintenance Organization
*Vendors
*Public Health Organizations.
Billing Claim Process
6 Steps
Step 1: Charge Entry
Step 2: Claims edits/scrubber (software)
Step 3: Bill Claims (send through a clearinghouse to the insurance carriers, or directly to the insurance carrier.
Step 4: Receive notification back from carrier (payment, denial)
Step 5: Post payments
Step 6: Work denials.
Cost-Based Fee Schedules
*Lease/ Rent payments, utilities
*Office supplies equipment
*Loan fees, maintenance fees
*Employee labor
*Malpractice/Liability Insurance
*Health Ins and other benefits cost
RVU-Based Fee Schedule
Use current Physician Fee Schedule Relative Value Units (PFS RVU)
*Create conversion factor
*Multiply by a given number.
Example:
If the national conversion factor for the 2023 is $33.89, and the PFS RVU file lists CPT 99214 w/ a non-facility RVU value of $3.76, the RVUs assigned are multiplied by the conversion factor to calculate the fee.
CPT 99214
$33.89 x 3.76 = $127.43 (round off)
If the office chooses to double the CMS fee … the conversion factor would be $67.78 (round off)
$67.78 x 3.76 = $254.85 (round off)
$255.
Can also be done using the national fee schedule for 99214 (127.43) and multiply by 2:
$127.43 x2 = $254.86 round off to $255.
A transposed code can cause
a denial for wrong code.
To help Reduce Payment Delay
*Verify Ins
*Submit Clean Claims
*Submit Claims electronically
*Check Status Reports
*Submit Documentation
*Post Contractual Adjustments
Prior Authorization
Required to obtain approval from health plan prior to providing a s/p/s
Claim Scrubbers
Software to Review Claims
SRC to check for errors before submitting claim.
A software that reviews claims for key components to id errors before claim is submitted.
Claim Scrubber common edits.
LCD: Local Coverage Determination
NCD: National Coverage Determination
*Demographic data entry
*Medical Necessity LCD/NCD
*Gender and age specific s/p
*DOS
*POS place of service
*Modifiers
*NCCI edits (bundling)
AR
Accounts Receivable
Money owed to practice for s/p rendered.
Daily Deposits
Balance each day - amount posted in the practice management system must match deposit amount for the batch.
Direct Deposits
Should match RA remittance advice sent to the provider from Ins carrier.
EDI
don’t confuse this w/ the Political
DEI: Diversity Equity Inclusion.
Electronic Data Interchange.
Minimizes claim rejections and resubmissions.
Delivers claims in real time.
Expedite payer response times.
Reduce cost of claim submissions.
Must meet HIPAA requirements.
DSL
Digital Subscriber Line
is a very high-speed connection.
software installed on the computer to use DSL.
Extranet
Is a private computer network that allows controlled access to the payer’s system.
It’s limited access to the payer patients only.
Internet
Vast computer network linking smaller computer networks worldwide.
Allows providers secure transmission of claims w/out the need for additional software.
Magnetic tape, disk, compact disc media magnetic tape, compact disc media
Claim can be mailed by disc
Clearinghouse
Billing companies and Practices utilize clearinghouses to submit claims.
Start on Video of Billing
Audits
Sample Encounter Form
1500 Claim Form
Report of Operation
Page 91
The term “item”
is used for the field on the paper CMS1500 claim form.
The term “loop”
is used in the electronic fields for the data elements to be sent.
The ASCA
Administrative Simplification Compliance Act
requires that claims be sent electronically, unless unusual circumstances are met.
EDI
ERA: Electronic Remittance Advice
Electronic Data Interchange.
Is computer-to-computer exchange of claims.
EDI replaces postal, fax, email etc.
for more information on the CMS1500 see web.
https://www.cms.gov/Outreach-and-Education/MLN/WBT/MLN4462429-MLN-WBT-1500/1500/index.html
The specific version for healthcare professionals and suppliers to transmit claims electronically is ANSI ASC X12N 837P. This is translated as:
aka P837 (electronic version of CMS1500)
ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting healthcare claims electronically
P = Professional version of the 837 electronic format
Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for healthcare professionals and suppliers.
Billing Tip
HIPAA allows filing paper claims when it has been determined that due to limitations in the claims’ transaction formats adopted, it would not be possible to submit the claim electronically. Exceptions allowing for paper claims to be filed to Medicare include:
MSP: Medicare Secondary Payer
*Roster billing of inoculations covered by Medicare.
*Claims for payment under a Medicare demonstration project that specifies paper submission.
*“Obligated to Accept as Payment in Full” (OTAF) Medicare Secondary Payer (MSP) claims when there is more than one primary payer
*MSP claims when there is more than one primary payer and more than one allowed amount.
Electronic claims can be submitted from the provider’s computer…
to a clearinghouse or directly to a payer.
Process
Claim is submitted to MAC
Medicare Admin Contractor
MAC sends claim through initial edits to determine claim has all requirements to meet the basic HIPAA requirements.
If errors are detected, at this level?
the entire batch of claims is rejected for correction and resubmission.
Once claims pass these front-end-edits
they are then edited against the HIPAA implementation guide requirements.
Claims that don’t meet these standards…
are rejected on an individual level and returned electronically to the provider for correction and resubmission.
After claim passes the first two edits…
the claim is then edited for compliance w/ Medicare coverage and policy requirements.
Claim is then adjudicated or processed by either?
denied or approved
After claims are successfully transmitted…
an acknowledgement report is generated.
Private payers
also process medical claims electronically, utilizing edits that reflect CPT coding guidelines and conventions, NCCI rules and CMS guidelines.
Paper claims are submitted to Medicare only on a limited basis.
Providers who qualify for a waiver as a result of an unusual circumstance must submit their waiver to a/b MACs DME MACs to who they submit their claims.
All fields of CMS1500 and UB04 claim forms must be?
completed according to payer specifications.
More information about the Accredited Standards Committee (ASC) X12 can be found at
https://x12.org.
The HIPAA implementation guide requirements are purchased through the Washington Publishing Company
(wpc-edi.com)
Many clearinghouse companies have the implementation standards built into their editing systems.
All major insurance payers have developed their individual claims submission methods…
*United Healthcare
*WellPoint
*Kaiser
*Humana
*Aetna
*Cigna
and others
Payers may offer…
claim submission/real-time adjudication options.
Review 8.1
Facility charges are reported on which claim form?
UB 04 Claim Form
What does the acronym NUCC stand for?
Answer: D.
National Uniform Claim Committee
What revisions does the CMS-1500 claim form undergo?
Multiple reviews prior to approval and implementation
Which transaction is NOT specified in the 5010 transaction standards?
Acknowledgement for Patient Payments
Rationale: The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).
What regulation requires claims to be sent electronically unless unusual circumstances are met?
Answer: A. Administrative Simplification Compliance Act (ASCA)
Rationale: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless unusual circumstances are met.
CMS 1500
“Items” are fields for data elements
CMS 1500 claim for the 837P
Format differs from Electronic to Paper CMS 1500 form
Paper = mmddccyy
Month - Day - Century- Year
Electronic = ccyymmdd
Century - Year - Month - Day
NUCC
National Uniform Claim Committee
02/12 1500 Claim Form Map
to the
X12 Health Care Claim:
Professional (837)
Includes data elements, identifiers, descriptions and codes from the Accredited Standards Committe X12, Ins Committee, ASC X12N, Health Care Claim: Professional (837) etc. etc.
The following is a crosswalk of the 02/12 version 1500 Health Care Form (1500 Claim Form) to the …
see example below on card 56 of changes from one form to another.
X12 837 Health Care Claim: Professional Version 5010-5010A1 electronic transaction.
see example below on card 56 of changes from one form to another.
1500 Form Locator
Item Title
Number
837P
Loop Id Segment/Data
Element
Overview of a claim
(by MAC)
c/r correction & resubmission
- Claim Received
- Initial Edits. The MAC sends the claim through initial edits to determine if the claim has all of the requirements necessary to meet basic HIPAA requirements. If any errors are found, the entire batch of claims is rejected for correction and resubmission.
- Edited against the HIPAA implementation guide requirements. Once the claims pass these front-end edits, they are then edited against HIPAA guidelines. Claims are rejected on an individual level and returned electronically to the provider for c/r.
- Edited for Compliance: after a claim passes through the first two sets of edits, the claim is then edited for compliance w/ Medicare coverage and payment policy requirements.
- Claim is then adjudicated: is the legal process by which an arbiter or judge reviews evidence and argumentation including legal reasoning set forth by opposing parties or litigants to come to a decision.
- Acknowledgement Report Generated: after claims are successfully transmitted and acknowledgement report is generated. The acknowledgement report can either be sent back to the provider or placed in an electronic mailbox for provider.
Services reported on the CMS 1500 claim form 837P.
*Inpatient s/p
*Observation, ER, Inpatient
*Surgeon’s charges
*Combined medical/surgical s/p
*Any s/p by Physician or supplier
*Ambulatory Surgical Centers ASCs
CMS 1500 Claim Form
is separated by a bold line in the middle of the form.
*Patient info top half of form
*Professional info bottom half of form.
CMS 1500 Claim Form
Blocks:
5, 4, 9, 17, 31, 33 for entering names.
When entering professional names
no commas are needed:
First name
Middle initial
Last name
Credentials
Patient’s name
example: commas are needed, last name first. see below.
Smith Jr, Ronald, B
CMS 1500 Claim Form
Block 5
Entering mailing address and phone
*Use only permanent address
on file w/ Ins Co
*Phone on file w/ Ins Co
*No dashes (except for 9-digit zip code) or other punctuation is allowed.
CMS 1500 Form
Block 7
When insured address is different than the beneficiary address.
For Worker’s Comp the address of the Employer is reported here.
CMS 1500 Claim Form
Block 9 and 11:
Primary vs. Secondary Payers
Block 9: is for Secondary payer info
Block 11: is for Primary payer info
Medigap Example on Block 9
- SAME (insured’s name)
a. MGAP12345678
d. 5500 (plan name or program name)
Block 10: Responsible Payers
- Is patient’s condition related to:
a. employment
b. auto accident
c. other accident
d. Claim Codes (designated by NUCC)
Block 13
Insured’s or authorized person’s signature.
Block 14
Date of IID
and
QUAL: qualifier 431 or 484
Current IID injury, illness, disease
or
LMP: Last Menstrual Period.
431: is for Onset of IID
484: is for LMP (for OB Visits)
Block 15
Other Date
QUAL:
enter applicable qualifier:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last Xray
471 Prescription
090 Report Start (Assumed care date)
091 Report End (relinquished care date)
444 First Visit/Consultation
Block 16
Dates patient unable to work in current occupation.
DOI? maybe but it doesn’t say that
Block 18
Hospitalization dates related to current s/p.
Block 17
Block 17: is for the referring provider.
17a:
Medicare: leave blank
OB State license number
1G Provider UPIN number
G2 Provider Commercial Number
LU Location Number (used for the Supervising Provider only)
17b:
NPI
Block 24 J:
A common reason for electronic claims rejection is for an invalid NPI.
J: Rendering Provider id #
On the shaded area of the block enter the non-NPI ID
On the non-shaded area enter the rendering provider’s NPI.
Block 12
Assignment of Benefits
Patient’s or Authorized person’s signature.
Signature on file
Block 27 Accepting Assignment
check box.
Yes or No
has to do with honoring the fee schedule. this does not mean you cannot appeal payments.
DO NOT CONFUSE:
Assignment of Benefits w/
Accept Assignment.
Block 21: Diagnoses
Sequencing diagnoses guidelines must be followed.
Primary diagnosis goes in A.________
CMS 1500 Claim Form
*One of the most common reasons for denials is inaccurate coding.
*Cannot use “probable”, “rule-out” etc.
*Signs and symptoms when definitive dx is unavailable.
*Must follow the documentation
*All dx codes must be reported w/ highest degree of specificity.
Block 24 Some Reminders
- A.
*Dates of service
*When “from” and “to” dates are show for a series of identical s/p.. enter the number of days or units in column G.
it’s a required item.
*The claim will NOT be processed if a DOS extends more than one day and a valid “to” date is not present.
Block 24 Reminders
- B.
Place of service is required.
Place of service code can be found in the front of the CPT codebook.
POS are necessary to support validity of services and must track to the HCPCS level 11 / CPT chosen.
Block 24. C.
EMG: Emergency s/p
Block 24. D.
s/p/s: service, procedure, supplies
*Enter the s/p/s using CPT and HCPCS
*You can also enter up to four modifiers.
*DO NOT use hyphens.
*When using an unlisted code (e.g. 77499) a narrative description of the s/p/s should be included.
*If NO description is included, claim will be rejected.
Block 24. E.
Diagnosis Pointer
*Enter the diagnosis code reference letter (A -L) not a letter as in una carta.
*letter show in item 21 to relate the DOS and s/p/s to the primary diagnosis code.
*Most payers only allow one reference number per line item
*It there are two or more dx that support s/p/s enter reference number as follows:
When multiple s/p/s… enter primary reference letter from A-L for each service first. DO NOT use commas if reporting multiple dx reference letters for one service.
For Medicare: If there are two or more dx that support s/p/s, the provider references only one of the dx in item 21.
Block 24. F.
$ Charges
*Enter charge for each s/p/s
*From fee schedule and are the same for each payer.
*Typed w/ no extra characters and dollar and cents go into their proper sections.
CMS 1500 Claim Form
Block 25: National Standard Employer Identifier
- Federal Tax I.D. Number
SSN EIN
SSN: Social Security Number
EIN: Employer Id Number
Block 33
Who gets the check.
The Biling Entity
Block 20: Outside Lab
*Outside lab reimbursement is equal to expense
Block 22 and 23: Medicaid
- Resubmission Code
Check w/ payer to determine utilization of this field.
When resubmitting a claim, enter the appropriate bill frequency:
7 Replacement of prior claim
8 Void/Cancel of prior claim
This item number is not used for original claim submissions.
Medicare: leave blank. not required.
Block 23
Prior Authorization Number
*NOT all payers require prior authorization.
*Can also be used for referral number
*Mammogram pre-certification number
*CLIA number for Lab when a CLIA s/p performed
*For HCPCS G0181 or G0182, the NPI of the home health agency or hospice agency is entered here.
*Only one condition is reported in this field. If additional conditions are required, they are reported on additional CMS 1500 claim forms.
Page 92
Billing Tip
More information about the Accredited Standards Committee (ASC) X12 can be found at https://x12.org.
The HIPAA implementation guide requirements are purchased through the Washington Publishing Company (wpc-edi.com). Many clearinghouse companies have the implementation standards built into their editing systems.
Review 8.1
Facility charges are reported on which claim form?
Answer: C. UB-04 claim form
What does the acronym NUCC stand for?
Answer: D. National Uniform Claim Committee
What revisions does the CMS-1500 claim form undergo?
Answer: D. Multiple reviews prior to approval and implementation
Which transaction is NOT specified in the 5010 transaction standards?
Answer: D. Acknowledgement for Patient Payments
Rationale: The 5010 transaction standards include Claims (837 Institutional, Professional, Dental, COB [Professional and Institutional] and, NCPDP), Claims Status Inquiry/Response (276/277), Remittance (835), Enrollment (834), Premium Payment (820), Eligibility Inquiry/Response (270/271), Referrals and Prior Authorizations (278), Claims Acknowledgements (277CA), Acknowledgement for Healthcare Insurance (999).
What regulation requires claims to be sent electronically unless unusual circumstances are met?
Answer: A. Administrative Simplification Compliance Act (ASCA)
Rationale: It is important to understand that the Administrative Simplification Compliance Act (ASCA) requires that claims be sent electronically unless unusual circumstances are met.
I have this Question already but remember the changes from the paper CMS1500 to the electronic claim 837P columns.
1500 837P
Item / Title Loop ID
Segment,
Data Element
CMS 1500 Claim Form
For Tricare
*Enter the DoD Benefits Number DBN (11-digit number) it’s found on the back of the card and it’s aka Electronic Data Interchange-Personal Identification number EDI-PI.
CMS 1500 Claim Form
For BCBS enter the ID number
CMS 1500 Claim Form
Item 8
*Leave blank
*This field is for NUCC use
Item 9b
*Leave blank. Field is for NUCC use.
Item 9c
*Leave blank if Item 9d is completed
Item 9—Enter the last name, first name, and middle initial of the insured if the patient has a secondary insurance. This is completed if Item 11d is marked YES.
Medigap: Complete this information if the patient has a Medigap (Medicare supplemental insurance) policy and the insured’s name is different from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.
NOTE: Only participating physicians and suppliers are to complete item 9 and its subdivisions and only when the beneficiary wishes to assign his or her benefits under a MEDIGAP policy to the participating physician or supplier.
Item 9a—Enter the policy and/or group number of the secondary insurance. (for example, Medigap policy number preceded by MEDIGAP, MG, or MGAP).
NOTE: Item 9d must be completed, even when the provider enters a policy and/or group number in item 9a.
Item 9b— Leave blank. This field is reserved for NUCC use.
Item 9c— Leave blank if Item 9d is completed. This field is reserved for NUCC use.
Item 9d—Enter the other insured’s insurance plan or program name.
Medigap: Enter the 5-digit Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID).
- SAME if name is spelled same as primary
9a. MGAP12345678
Items 10a through 10c—Check YES or NO to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in item 24. Enter the state postal code. Any item checked YES indicates there may be other insurance primary to the patient’s health insurance.
For example, if the encounter was to treat a patient’s injury while at work, workers’ compensation is the primary payer not the patient’s health insurance. Identify primary insurance information in item 11.
Item 10d—When applicable, use to report appropriate claim codes. Please refer to the most current instructions from the public or private payer regarding the need to report claim codes.
Claim codes can be entered in this item to identify additional information about the patient’s condition on the claim. Current claim codes include condition codes. Condition codes approved for use in this item can be found at: https://www.nucc.org/index.php/code-sets-mainmenu-41/condition-codes-mainmenu-38
MCD
the patient’s Medicaid number
Item 11—This item contains the insured’s policy, group, or FECA number (9-character identifier assigned to a patient claiming work-related condition(s) under the Federal Employees Compensation Act 5 USC 8101) as it appears on the insured’s healthcare identification card. Do not use a hyphen or space as a separator within the policy or group number. If item 4 is completed, this item must also be completed.
Medicare: This item is required by Medicare. By completing this item, the physician/supplier acknowledges having made a good faith effort to determine whether Medicare is primary or secondary payer. If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to items 11a–11c. This is determined by having the patient complete the Medicare Secondary Questionnaire. Items 4, 6, and 7 must also be completed.
FECA
Federal Employees Compensation Act
Billing Tip
Medicare provides a list of questions to ask beneficiaries during the registration process to determine if Medicare is the secondary payer. This can be found in the Medicare Secondary Payer (MSP) Manual, Chapter 3, Section 20.2.1—Admission Questions to Ask Medicare Beneficiaries.
Item 11a—Enter the insured’s 8-digit birth date (MM|DD|CCYY) and sex. If the gender is unknown, leave it blank.
Item 11b—Enter a qualifier (for example, Y4 Property Casualty Claim Number) followed by the identifier number.
11b
For Medicare, enter employer’s name. If there is a change in the insured’s insurance status (for example, retired), enter either a 6-digit (MM|DD|YY) or 8-digit (MM|DD|CCYY) retirement date preceded by the word RETIRED. This information should be entered to the right of the vertical dotted line.
