Health Care Claim Preparation & Transmission

1. Health Care Claim Preparation & Transmission Chapter 8 OT 232 Lecture 2 OT 232 Ch 8 lecture 1

2. Completing the CMS-1500 Claim (cont’d) • IN 32 • Service Facility Location Information • Used for information if different than IN33 • Used for providers of diagnostic tests or radiology services • IN 33 • Provider’s billing info • Taxonomy codes • Another form of id that stands for a physician’s specialty • Used also if pay can be affected • Appendix A, page 633 • Awesome summary for CMS-1500, page 262-3 OT 232 Ch 8 lecture 1

3. Completing the HIPAA 837 Claim • 837 P • ‘P’ stands for professional services • Used by physicians • 837 I • ‘I’ stands for institutional • Used by hospitals • PMP vendors are responsible for • Keeping the product up-to-date • Getting certification from HIPAA that their software accommodates HIPAA-mandated transactions • Train personnel to use new features OT 232 Ch 8 lecture 1

4. Completing the HIPAA 837 Claim(cont’d.) • PMP’s pull data elements to complete form • Pieces of information • 4 types • R – Required • RIA – Required if applicable • Ex. insured differs from patient • NRUC – Not required unless specified under contract • Flex boxes • NR – Not required • In provider’s records but payer doesn’t need, or already has this info • 837 is organized differently than the 1500 • More efficient • There is a hierarchy to how info is sent, so the only data elements that have to be sent are those that don’t repeat previous data OT 232 Ch 8 lecture 1

5. Completing the HIPAA 837 Claim(cont’d.) • Provider info • So if a batch of claims is sent, provider data is sent once and used for all • 4 types of providers • Billing provider • Sending the claim • Pay-to provider • Person or organization that will receive payment for services reported on the claim • Rendering provider • Medical professional who provides the service being reported • Referring provider • Physician who refers the patient to another physician for treatment • One claim could involve all 4 • Dr. A is the referring provider who refers the patient to the rendering physician Dr. B who works for the pay-to provider, Clinic C, and Clinic C uses a clearinghouse as a billing provider to transmit its claims. Whew! • Or one… • The rendering provider bills for his services and receives payment! OT 232 Ch 8 lecture 1

6. Completing the HIPAA 837 Claim(cont’d.) • Subscriber and patient info • 1500 uses ‘insured’, 837 uses ‘subscriber’ (Many benefits to electronic form, including more options) • Claim filing indicator code • Identifies type of plan • Valid until a National Payer ID system is in place • Table 8.5 on page 268 • Relationship of Patient to Subscriber • Vs. 1500? • Table 836, page 269 • Other data elements • Used if another payer is involved • Patient-specific information OT 232 Ch 8 lecture 1

7. Completing the HIPAA 837 Claim(cont’d.) • Payer info • Payer obviously knows it’s own info, but helpful for CoB • Coordination of Benefits • Remember the order of responsible payers? Primary… • Secondary, Tertiary, Supplemental • Claim info • Info related to a particular claim • Claim Control Number • Unique for each claim, NOT the patient’s account number • Claim Frequency Code • Aka ‘Claim Submission Reason Code’ • ‘1’ on the initial claim • ‘7’ on a replacement claim (so they know it’s not a double bill) • ‘8’ to cancel prior claim OT 232 Ch 8 lecture 1

8. Completing the HIPAA 837 Claim(cont’d.) • Diagnosis Code • Different from 1500, because can list 8 • (4 on 1500) • Still must be directly related to treatment • Claim note • “flex box” • Service Line Information • Diagnosis Code Pointers • From codes, links to procedures • Line Item Control Number • Tracks for services rather than claims • Service lines are numbered by sender, so easier to match up when payments are made OT 232 Ch 8 lecture 1

9. Completing the HIPAA 837 Claim(cont’d.) • Claim Attachments • Separate page of info to support the claim • Currently no standard form • Credit/Debit info • Consent form to bill after adjudication • Clearinghouses and Claim Transmission • Check claims • Transmit claims • Directly OT 232 Ch 8 lecture 1

10. Claim Transmission (cont’d.) • Clearinghouse • Benefits? • Accept nonstandard formats and translates them into standard • Maps the content of each data element according to the payer’s instructions • Cannot create or modify data, ‘fix’ the claim • Edits the claim and returns to provider for corrections or missing information • Direct Data Entry – DDE • Web based claim form • Billing providers enters info which goes straight to the payers • Clean claims vs. Dirty Claims OT 232 Ch 8 lecture 1