chapter 21 the health insurance claim form
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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. - PowerPoint PPT PresentationTRANSCRIPT
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
Copyright © 2014 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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.
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Lesson 21.1
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Introduction
Universal claim form (CMS-1500 Health Insurance Claim Form) Used to submit all insurance claims
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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
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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
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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)
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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
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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
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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
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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])
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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
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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
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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
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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
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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%
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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)
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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
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Preauthorization and/or Referral
If required, perform preauthorization to obtain authorization number
Place this number in Block 23 on CMS-1500 form
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Completing the CMS-1500 Form
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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
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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
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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
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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
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CMS-1500 Claim Form: Patient and Insured Information––Blocks
1 to 8
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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
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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
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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
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Section 3: Patient/Insured Section
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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
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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)
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Section 3: Blocks 11a-11d
Completed for primary insurance claim Use Box 1a as reference to fill out these
blocks
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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
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CMS-1500 Claim Form
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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
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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
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Physician/Supplier Section—Blocks 24 to 33
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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
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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
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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
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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
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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.
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Lesson 21.2
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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
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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
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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 44
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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 45
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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
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Explanation of Benefits
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(From Hunt SA: Saunders fundamentals of medical assisting, Philadelphia, 2002, WB Saunders.)
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Checking a Claim’s Status
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(From Fordney MT: Insurance handbook for the medical office, ed 12, St Louis, 2012, WB Saunders.)
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Insurance Aging Report
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(From Hunt SA: Saunders fundamentals of medical assisting, Philadelphia, 2002, WB Saunders.)
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Audit Trails
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Tickler File
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(From Fordney MT: Insurance handbook for the medical offi ce, ed 12, St Louis, 2012, WB Saunders.)
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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
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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
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Questions?
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