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Chapter 21 The Health Insurance Claim Form

TEACH Lesson Plan Manual for Kinn’s The Medical Assistant: An Applied Learning Approach 12 th edition. Chapter 21 The Health Insurance Claim Form. Completing the CMS-1500 Claim Form. Define , spell, and pronounce the terms listed in the vocabulary.

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Chapter 21 The Health Insurance Claim Form

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  1. TEACH Lesson Plan Manual for Kinn’s The Medical Assistant: An Applied Learning Approach 12th edition Chapter 21 The Health Insurance Claim Form

  2. Completing the CMS-1500 Claim Form Define, spell, and pronounce the terms listed in the vocabulary. Discuss the differences between paper claims and electronic claims. Understand the guidelines for completing the CMS-1500 Health Insurance Claim Form. Explain how to complete each of the blocks of the CMS-1500 claim form. Gather information for use on insurance claim forms. Complete a CMS-1500 claim form appropriately for various federal, state, and commercial third-party payers. Lesson 21.1

  3. Introduction • Universal claim form (CMS-1500 Health Insurance Claim Form) • Used to submit all insurance claims

  4. Hard Copy (Paper) Claims • Advantages: • Minimal start-up costs • Ability to attach documentation • Disadvantages: • Higher cost in time, labor, and postage • Slower reimbursement • Greater storage space

  5. Intelligent Character Recognition • System that scans documents and captures claims information directly from CMS-1500 form • Scanners transfer information on claim forms into computers • Benefits of ICR scanning: • Greater efficiency in processing claims • Improved accuracy • More control over data input • Reduced data entry cost for insurance carrier

  6. Rules for Paper CMS-1500 Form • Entries should be clear and sharp; carbon copies are not acceptable • Use pica type (10 characters per inch) • All uppercase letters should be used • All punctuation should be omitted • All birth dates should be in this format: • MM DD YYYY (with a space between each set of digits)

  7. Rules for Paper CMS-1500 Form, cont’d • Each entry should be kept within its respective block • All characters must fall completely within designated block • A blank space should be substituted for the following: • Dollar signs and decimal points in charges and in ICD-9-CM codes • Dashes preceding procedure code modifiers • Parentheses around telephone area codes • Hyphens in SSNs

  8. Rules for Paper CMS-1500 Form, cont’d • Titles and other designations should be omitted unless they appear on ID card • When charge is expressed in whole dollars, two zeros should be used in “cents” column • Do not enter alpha character “O” for a zero (0) • If a typewriter is used, do not use lift-off tape, correction tape, or correction fluid

  9. Rules for Paper CMS-1500 Form, cont’d • All resubmissions must be prepared using original (red print) claim form • No handwritten data (other than signatures) may be included on form • Nothing should be stapled to form • The name and address of insurance company should be inserted in the proper area in top margin of claim form

  10. Electronic Claims • Insurance claims transmitted over Internet from provider to health insurance company • Transaction and code set for CMS-1500 electronic claims submission is the ASC X12N 837P (HIPAA 837 Health Care Claim: Professional [837P])

  11. Professional (837P) Overview • Standards mandate the format of electronically submitted forms to protect patients’ health information and privacy • HIPAA 837 Health Care Claim: Professional, or 837P • Insurance claim form for physician and provider services • Used to submit healthcare claim billing information, encounter information, or both from providers of healthcare services to payers

  12. Direct Billing • Process by which an insurance carrier allows provider to submit claims directly to carrier electronically • Most major insurance carriers provide computer program to enter data for submission; transmitted directly to carrier

  13. Clearinghouse Submission • Clearinghouse: • Vendor that allows a provider to submit all insurance claims generated by provider to clearinghouse using special software • Audits and sorts claims and sends electronically to different carriers • Charges provider a fee to process and submit claims to insurance payers

  14. Other Services Provided by Clearinghouses • Auditing claims to make sure all required fields are completed and data are correct • Reporting number of claims submitted and number of errors and their specifics • Forwarding claims to insurance carriers that accept electronic claims or to another clearinghouse that may hold contracts with specific payers • Keeping provider offices updated as new carriers are added to database • Generating informative statistical reports

  15. Advantages of Electronic Submission • Payments usually received in half the time of paper claims • Clearinghouses will send tracking reports on claim status, including if additional information is needed • Reduces error rates to less than 2%

  16. Data Gathering Guidelines • Always gather insurance information from new patients, as well as asking returning patients to confirm information for accuracy • Information needed to complete insurance form comes from: • Patient Registration form • Completed Verification of Eligibility and Benefits form • Referral and authorization information (when required) • Patient’s medical record • Encounter form or charge ticket • Photocopy of patient’s insurance card/s, driver’s license or state-issued ID card, and student ID (if applicable and available)

  17. Verification of Eligibility and Benefits • Next step is to verify patient’s eligibility and benefits • Usually done by calling insurance carrier for patient and confirming coverage • Information should be verified by fax or e-mail confirmation from carrier

  18. Preauthorization and/or Referral • If required, perform preauthorization to obtain authorization number • Place this number in Block 23 on CMS-1500 form

  19. Completing the CMS-1500 Form

  20. Three Sections of CMS-1500 Form • Section 1: Carrier Block—first section contains address of insurance carrier and is located at top of form • Section 2: Patient/Insured Section—second section contains information about patient and insured; it includes Boxes 1 through 13 • Section 3: Physician/Supplier Section––third section contains information about physician or supplier; it includes Boxes 14 through 33

  21. Section 1: Carrier Block • Name and address of payer is entered in this block • Payer is carrier, health plan, third-party administrator, or other payer who will process claim

  22. Section 2: Patient/Insured Section––Block 1 • Block 1: Type of Insurance • Indicate type of health insurance coverage applicable to this claim by putting an X in appropriate box • This information directs claim to correct payer and may establish primary liability • Block 1a: Insured’s ID Number—ID number of person who holds the policy

  23. Section 2: Blocks 2-4 • Block 2: Patient’s Name—name of patient is person who received treatment or supplies • Block 3: Patient’s Birth Date and Sex—patient’s birth date and sex help identify patient and distinguishes patients with similar names • Block 4: Insured’s Name—name of person who holds the policy

  24. CMS-1500 Claim Form: Patient and Insured Information––Blocks 1 to 8

  25. Section 2: Block 4––Determining Primary and Secondary Insurance • If patient is insured, patient’s insurance is primary and any insurance carried by spouse or guarantor is secondary • In case of a child whose parents each carry child as dependent on separate policies, use birthday rule

  26. Section 2: Blocks 5 and 6 • Block 5: Patient’s Address––patient’s permanent address and telephone number are entered here • Block 6: Patient Relationship to Insured––self, spouse, child, other

  27. Section 2: Blocks 7 and 8 • Block 7: Insured’s Address—insured’s permanent address and telephone number are entered here • Block 8: Patient Status—these boxes are important for determining liability and for coordinating benefits • Single, married, other, employed, full-time student or part-time student

  28. Section 3: Patient/Insured Section

  29. Section 3: Blocks 9a-9d • Only complete Block 9 if billing a secondary insurance policy • Blocks 9a-9d include secondary insurance policy number and demographic information

  30. Section 3: Blocks 10a-10d • 10a-c indicates what patient’s condition is related to • 10d is reserved for local use (for some third-party payers)

  31. Section 3: Blocks 11a-11d • Completed for primary insurance claim • Use Box 1a as reference to fill out these blocks

  32. Section 3: Blocks 12 and 13 • Block 12 is for patient or authorized person’s signature to release medical information to process claim • Block 13 is for insured’s or authorized person’s signature to authorize payment of medical benefits directly to provider in Blocks 31 and 32

  33. CMS-1500 Claim Form

  34. Physician/Supplier Section—Blocks 14 to 23 • Block 14 is for the date current illness, condition, or injury began • Block 15 is for onset date of similar previous conditions • Block 16 refers to dates patient was unable to work; used for disability payments • Block 17 is for referring provider or other source • Block 17a: Other ID • Block 17b: NPI is for individual national ID number assigned by HIPAA

  35. Physician/Supplier Section—Blocks 14 to 23, cont'd • Block 18 is for dates of hospitalization related to claim • Block 19 is for payers asking for certain identifiers • Block 20 refers to diagnostic laboratory services rendered by separate provider • Block 21 refers to signs, symptoms, complaint or condition of patient • Block 22 is for code and reference number if Medicaid payment is needed • Block 23 is the payer-assigned number authorizing service, procedure, or referral

  36. Physician/Supplier Section—Blocks 24 to 33

  37. Physician/Supplier Section—Blocks 24A-E • Block 24A is for date that service was provided • Block 24B identifies where service was provided; use POS code • Block 24C indicates whether services provided involved an emergency • Block 24D is for identifying codes for reporting services and procedures • Block 24E is for diagnosis code or reference number

  38. Physician/Supplier Section—Blocks 24F-J • Block 24F is total billed amount for each service line • Block 24G refers to number of days that correspond to dates entered • Block 24H identifies certain services covered under state plans • Block 24I is for the rendering provider • Block 24J is for the NPI number of rendering provider

  39. Physician/Supplier Section—Blocks 25-30 • Block 25 is for federal tax ID number • Block 26 is the patient's account number assigned by provider of service • Block 27 is for provider to accept assignment under terms of some insurance payers • Block 28 is amount billed on this claim form for all services rendered • Block 29 is amount received from patient or other payers • Block 30 is amount left after patient has paid a co-pay or co-insurance

  40. Physician/Supplier Section—Blocks 31 to 33b • Block 31 is for signature of provider to verify claim is correct • Block 32 is for service facility address • Block 33a is for NPI number of service facility • Block 33b is for billing provider's non-NPI identifier, if there is no NPI

  41. Preventing Claims Rejections Differentiate between “clean” and “dirty” claims. Discuss methods of preventing claims rejections. Describe ways of checking the status of claims. Lesson 21.2

  42. Guidelines for Claims Review Before Submission • Proofread form carefully for accuracy and completeness • Make certain any necessary attachments are included with completed form • Follow office policies and guidelines for claim review and signatures • Forward original claim to the proper insurance carrier either by mail or electronically • Make a copy of completed paper claim and signed claim form for the office records

  43. Guidelines for Claims Review Before Submission, cont’d • Enter appropriate information in insurance log and record insurance submission information on patient’s ledger • Make sure patient information matches insurance card exactly • Patient’s birth date and gender must match medical record • Enter NONE in Block 11 if Medicare is payer

  44. Guidelines for Claims Review Before Submission, cont’d • Provider’s name and NPI number should be entered in Blocks 17 and 17a, if applicable • In Block 27, put an X in YES box if the physician is a participating provider (PAR) • Make sure diagnosis is not missing or incomplete • Diagnosis must be coded accurately • Patient must have authorized the release of information

  45. Guidelines for Claims Review Before Submission, cont’d • Section 2, Patient/Insured Section, completed accurately according to guidelines • Fees for each charge must be listed individually • All required fields of diagnosis and procedure section accurate • Physician’s signature must be on form • Provider’s federal TIN, EIN, or SSN should be double-checked • Physician’s NPI should be entered in Block 24K and again in Block 33

  46. Preventing Claim Rejection • Follow guidelines to prevent delays or rejection of reimbursement • Medicare, Medicaid, TRICARE, workers' compensation guidelines found online • Software billing programs usually have "claims scrubbers" to help identify mistakes • Clean claims are without errors • Technical errors and insurance policy coverage issues are main reasons for denial of payment

  47. Explanation of Benefits (From Hunt SA: Saunders fundamentals of medical assisting, Philadelphia, 2002, WB Saunders.)

  48. Checking a Claim’s Status (From Fordney MT: Insurance handbook for the medical office, ed 12, St Louis, 2012, WB Saunders.)

  49. Insurance Aging Report (From Hunt SA: Saunders fundamentals of medical assisting, Philadelphia, 2002, WB Saunders.)

  50. Audit Trails

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