Chapter 7Chapter 7

The Paper Claim: CMS-1500 (08-05) The Paper Claim: CMS-1500 (08-05)

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Learning ObjectivesLearning Objectives

Discuss the history of the Health Insurance Claim Discuss the history of the Health Insurance Claim Form (CMS-1500 [08-05]).Form (CMS-1500 [08-05]).

State when the CMS-1500 (08-05) claim form State when the CMS-1500 (08-05) claim form may or may not be used.may or may not be used.

Define the two types of claims submission.Define the two types of claims submission. Explain the difference between clean, pending, Explain the difference between clean, pending,

rejected, incomplete, and invalid claimsrejected, incomplete, and invalid claims Abstract from the patient record relevant Abstract from the patient record relevant

information for completing the CMS-1500 (08-05) information for completing the CMS-1500 (08-05) insurance claim form.insurance claim form.

Describe reasons why claims are rejected.Describe reasons why claims are rejected.

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Learning Objectives (cont’d)Learning Objectives (cont’d)

Describe basic guidelines for submitting Describe basic guidelines for submitting insurance claims.insurance claims.

Explain procedures that will minimize the Explain procedures that will minimize the number of insurance forms returned number of insurance forms returned because of improper completion.because of improper completion.

Identify techniques required for optically Identify techniques required for optically scanned insurance claims.scanned insurance claims.

Demonstrate the ability to complete the Demonstrate the ability to complete the CMS-1500 (08-05) claim form accurately for CMS-1500 (08-05) claim form accurately for federal, state, and private payer insurance federal, state, and private payer insurance contracts using current basic guidelines.contracts using current basic guidelines.

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Chapter 7Chapter 7

Lesson 7.1Lesson 7.1

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History of the Claims ProcessHistory of the Claims Process

Standard form created in 1958.Standard form created in 1958. AMA approved a “universal claim form” AMA approved a “universal claim form”

in 1975.in 1975. Originally called Health Insurance Claim Form Originally called Health Insurance Claim Form

(HCFA-1500)(HCFA-1500) Now called CMS-1500 (08-05)Now called CMS-1500 (08-05)

Revised form made available for optical Revised form made available for optical scanning in 1990.scanning in 1990.

Revised form for NPI inclusion made Revised form for NPI inclusion made available in 2005.available in 2005.

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Types of ClaimsTypes of Claims

Paper claimPaper claim Submitted on paper or optically scannedSubmitted on paper or optically scanned Typed or computer-generatedTyped or computer-generated

Electronic claimElectronic claim Submitted via electronic methodSubmitted via electronic method Digital file not printed on paperDigital file not printed on paper

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Claim StatusClaim Status

Clean claim: claim was submitted within the Clean claim: claim was submitted within the program or policy time limit and contains all program or policy time limit and contains all necessary informationnecessary information

Physically clean claim: has no staples or Physically clean claim: has no staples or highlighted areas, bar code area has not highlighted areas, bar code area has not been deformedbeen deformed

Rejected claim: not processed or cannot be Rejected claim: not processed or cannot be processedprocessed

Pending claim: held in suspense because of Pending claim: held in suspense because of review or other reasonreview or other reason

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Claim Status (cont’d.)Claim Status (cont’d.)

Incomplete claim: missing required Incomplete claim: missing required informationinformation

Invalid claim: contains complete, necessary Invalid claim: contains complete, necessary information but is illogical or incorrectinformation but is illogical or incorrect

Dirty claim: submitted with errors, requiring Dirty claim: submitted with errors, requiring manual processing for resolution, or rejected manual processing for resolution, or rejected for paymentfor payment

Deleted claim: canceled, deleted, or voided Deleted claim: canceled, deleted, or voided by a Medicare fiscal intermediaryby a Medicare fiscal intermediary

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Reasons for Abstracting From Reasons for Abstracting From Medical RecordsMedical Records

To complete insurance claim formsTo complete insurance claim forms When sending a letter to justify a health When sending a letter to justify a health

insurance claim after professional services insurance claim after professional services are renderedare rendered

When a patient applies for life, mortgage, or When a patient applies for life, mortgage, or health insurancehealth insurance

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Insurance Application FormInsurance Application Form

Part I: filled out by insurance agent during Part I: filled out by insurance agent during interview with clientinterview with client

Part II: filled out by prospective insuredPart II: filled out by prospective insured Part III: filled out by physician during office Part III: filled out by physician during office

visitvisit

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Abstracting ExamplesAbstracting Examples

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Abstracting Examples (cont’d.)Abstracting Examples (cont’d.)

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Basic Guidelines for Submitting a Basic Guidelines for Submitting a ClaimClaim

Individual insuranceIndividual insurance Group insuranceGroup insurance Secondary insuranceSecondary insurance

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Completion of Insurance FormsCompletion of Insurance Forms

DiagnosisDiagnosis Service datesService dates Consecutive datesConsecutive dates No chargeNo charge Physician’s identification numbersPhysician’s identification numbers Insurance biller’s initialsInsurance biller’s initials ProofreadProofread Supporting documentationSupporting documentation Office pending fileOffice pending file

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Common Reasons for Claim Common Reasons for Claim Delay or RejectionDelay or Rejection

Claim submitted to the secondary insurer instead of the Claim submitted to the secondary insurer instead of the primary insurer.primary insurer.

Information missing on patient portion of the claim form.Information missing on patient portion of the claim form. Patient’s insurance number is incorrect or transposed.Patient’s insurance number is incorrect or transposed. Patient’s name and insured’s name are entered as the Patient’s name and insured’s name are entered as the

same when the patient is a dependent.same when the patient is a dependent. Failure to indicate whether patient’s condition is related Failure to indicate whether patient’s condition is related

to employment or an “other” type of accident.to employment or an “other” type of accident. Patient’s signature is missing.Patient’s signature is missing. Physician’s signature is missing.Physician’s signature is missing.

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Chapter 7Chapter 7

Lesson 7.2 Lesson 7.2

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Optical Scanning Do’s and Dont’sOptical Scanning Do’s and Dont’s

DO: use black typewriter ink, high carbon content DO: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons. one-time Mylar, or OCR printer ribbons.

DO: use original claim forms printed in red ink; DO: use original claim forms printed in red ink; photocopiesphotocopies1717 cannot be scanned. cannot be scanned.

DO: align the typewriter or printer correctly so DO: align the typewriter or printer correctly so characters appear in the proper fields.characters appear in the proper fields.

DO: enter all information In upper case letters.DO: enter all information In upper case letters. DO: use alpha or numeric symbols.DO: use alpha or numeric symbols. DO: enter eight-digit date formats.DO: enter eight-digit date formats. DO: keep signature within signature block.DO: keep signature within signature block.

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Optical Scanning Do’s and Dont’s Optical Scanning Do’s and Dont’s (cont’d.)(cont’d.)

DON’T: allow characters to touch lines.DON’T: allow characters to touch lines. DON’T: use script, slant, minifont, or italicized fonts DON’T: use script, slant, minifont, or italicized fonts

or expanded, compressed, bold, or proportional print. or expanded, compressed, bold, or proportional print. DON’T: hand write information on the document.DON’T: hand write information on the document. DON’T: strike over errors when correcting or crowd DON’T: strike over errors when correcting or crowd

preprinted numbers.preprinted numbers. DON’T: use highlighter pens or colored ink.DON’T: use highlighter pens or colored ink. DON’T: use symbols (#, -, /), periods(.), ditto marks, DON’T: use symbols (#, -, /), periods(.), ditto marks,

parentheses, or commas(,).parentheses, or commas(,). DON’T: use N/A or DNA when information is not DON’T: use N/A or DNA when information is not

applicable.applicable.

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CMS-1500 Claim Form CMS-1500 Claim Form Instructions Top of FormInstructions Top of Form

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Block 24B (cont’d.)Block 24B (cont’d.)

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Insurance Program Template 1Insurance Program Template 1

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Insurance Program Template 2Insurance Program Template 2

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Insurance Program Template 3Insurance Program Template 3

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Insurance Program Template 4Insurance Program Template 4

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Insurance Program Template 5Insurance Program Template 5

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Insurance Program Template 6Insurance Program Template 6

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Insurance Program Template 7Insurance Program Template 7

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Insurance Program Template 8Insurance Program Template 8

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Insurance Program Template 9Insurance Program Template 9

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Insurance Program Template 10Insurance Program Template 10