chapter 21 the health insurance claim form

Copyright © 2014 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 21The Health Insurance Claim Form

TEACH Lesson Plan Manual for Kinn’s The Medical Assistant: An Applied

Learning Approach

12th edition

1


Completing the CMS-1500 Claim Form

1. Define, spell, and pronounce the terms listed in the vocabulary.

2. Discuss the differences between paper claims and electronic claims.

3. Understand the guidelines for completing the CMS-1500 Health Insurance Claim Form.

4. Explain how to complete each of the blocks of the CMS-1500 claim form.

5. Gather information for use on insurance claim forms. 6. Complete a CMS-1500 claim form appropriately for

various federal, state, and commercial third-party payers.

2

Lesson 21.1


Introduction

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

3


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

4


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

5


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)

6


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

7



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

8



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

9


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])

10


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 11


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

12


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

13


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

14


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%

15


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)

16


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

17


Preauthorization and/or Referral

If required, perform preauthorization to obtain authorization number

Place this number in Block 23 on CMS-1500 form

18


Completing the CMS-1500 Form

19


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

20


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

21


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

22


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

23


CMS-1500 Claim Form: Patient and Insured Information––Blocks

1 to 8

24


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

25


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

26



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

27


Section 3: Patient/Insured Section

28


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

29



10a-c indicates what patient’s condition is related to

10d is reserved for local use (for some third-party payers)

30



Completed for primary insurance claim Use Box 1a as reference to fill out these

blocks

31



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

32


CMS-1500 Claim Form

33


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

34


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

35


Physician/Supplier Section—Blocks 24 to 33

36


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

37


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

38


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 39


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

40


Preventing Claims Rejections

7. Differentiate between “clean” and “dirty” claims.

8. Discuss methods of preventing claims rejections.

9. Describe ways of checking the status of claims.

41

Lesson 21.2


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

42


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

43



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 44



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 45


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

46


Explanation of Benefits

47

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


Checking a Claim’s Status

48

(From Fordney MT: Insurance handbook for the medical office, ed 12, St Louis, 2012, WB Saunders.)


Insurance Aging Report

49

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


Audit Trails

50


Tickler File

51

(From Fordney MT: Insurance handbook for the medical offi ce, ed 12, St Louis, 2012, WB Saunders.)


Patient Education

Be able to explain confusing technical issues to patients in simple terms

Insurance issues are confusing and frustrating to patients

Keep patients informed of changes in insurance guidelines

52


Legal and Ethical Issues

Stay current on the laws that affect medicine, federal and state insurance programs

HIPAA is responsible for implementation of various laws that protect individuals’ health insurance and privacy standards

Identify potential compliance problems and correct them before a liability risk is incurred

53


Questions?

54

chapter 21 the health insurance claim form

Documents