The paper claim: cms-1500 (02-12) Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Background & Submission of the CMS-1500 Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Learning Objectives Discuss the history of the Health Insurance Claim Form (CMS-1500 [08-05]). Define the two types of claims submission. Explain the difference between clean, pending, rejected, incomplete, and invalid claims Abstract from the patient record relevant information for completing the CMS-1500 (08-05) insurance claim form. Describe basic guidelines for submitting insurance claims. Describe reasons why claims are rejected. Explain procedures that will minimize the number of insurance forms returned because of improper completion. Identify techniques required for optically scanned insurance claims.

History of the Claims Process Standard form created in 1958 AMA approved a “universal claim form” in 1975. Originally called Health Insurance Claim Form (HCFA-1500) Now called CMS-1500 (02-12) Revised form made available for optical scanning in 1990 Revised form for NPI inclusion made available in 2005 Revised from for ICD-10 made available in 2014 Describe the advantages of the CMS-1500 (08-05). (Standard format will expedite claims processing.) Explain why the changes were made over time. (Claim submission technology changed and new information was required on the claim form, so changes were necessary.) When the ICD-10-CM is adopted in 2013, claims must be able to accommodate as many as ten to twelve 7-digit diagnostic codes per claim. Because of this, the CMS-1500 will morph into the Uniform Bill (UB-04) claim format and will become the electronic ASC X12 version 5010 to be implemented in 2012. The UB-04 is the form used for inpatient hospital claims and is discussed in more detail in Chapter 17. Chapter 8 explains ASC X12 version 5010.

Types of Claims Paper claim Submitted on paper or optically scanned Typed or computer-generated Electronic claim Submitted via electronic method Digital file not printed on paper What electronic methods are used to submit an electronic claim? (Modem, direct data entry, DSL, FTP)

Claim Status Clean claim: claim was submitted within the program or policy time limit and contains all necessary information Physically clean claim: has no staples or highlighted areas, bar code area has not been deformed Rejected claim: not processed or cannot be processed Pending claim: held in suspense because of review or other reason List the four criteria for a clean claim according to Medicare. (No deficiencies and passes all electronic edits, carrier does not need to investigate before paying the claim, claim is investigated on a postpayment basis, claim is subject to medical review with attached information or forwarded simultaneously with EMC records) Give the general term for Medicare claims that are not considered “clean” and which require investigation or development on a prepayment basis (“other” claims).

Claim Status (cont’d.) Incomplete claim: missing required information Invalid claim: contains complete, necessary information but is illogical or incorrect Dirty claim: submitted with errors, requiring manual processing for resolution, or rejected for payment Deleted claim: canceled, deleted, or voided by a Medicare fiscal intermediary Explain how these claims are handled. (Most claims can be resubmitted with additional information.) Describe the time limit for processing participating provider electronic submissions (within 14 days of receipt) and for paper submissions (27 days after receipt).

Completion of Insurance Forms Diagnosis Service dates Consecutive dates No charge Physician’s identification numbers Insurance biller’s initials Proofread Supporting documentation Office pending file A diagnosis should never be submitted without supporting documentation in the medical record. Dates must be consistently formatted in all blocks on the claim form. Should a claim be filed if there was no charge for a service? (No.) Be sure to use the correct identification numbers on the claim form. Be sure the physician signs and initials claims, where appropriate. What should be included on all supporting documentation? (Patient’s name, subscriber’s name, date of service, insurance identification number)

Common Reasons for Claim Delay or Rejection Submitted to secondary instead of primary Missing information Insurance ID # is incorrect Subscriber information incorrect Failure to indicate whether patient’s condition is related to employment or an “other” type of accident Patient or provider signature is missing Ask students to list other common reasons. (Answers will vary.) Discuss how each of these reasons for rejection can be avoided. See Table 7-1

Do’s and dont’s for Completing the CMS-1500 Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Optical Scanning Do’s and Don’ts DO: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons. DO: use original claim forms printed in red ink; photocopies cannot be scanned DO: align the typewriter or printer correctly so characters appear in the proper fields DO: enter all information in upper case letters DO: use alpha or numeric symbols DO: enter eight-digit date formats DO: keep signature within signature block Explain the benefits of OCR. (More control over data input, improved accuracy, increased efficiency in processing)

Optical Scanning Do’s and Don’ts (cont’d.) DON’T: allow characters to touch lines DON’T: use non-standard fonts DON’T: handwrite information on the document DON’T: strike over errors when correcting or crowd preprinted numbers DON’T: use highlighter pens or colored ink DON’T: use symbols (#, -, /), periods(.), ditto marks, parentheses, or commas(,) DON’T: use N/A or DNA when information is not applicable Explain why these items are incorrect, and refer students to the previous slide or the textbook for the correct methods.

Instructions for completing the cms-1500 claim form

Patient information

Completing the CMS-1500 Claim Form The following instructions explain how to complete the paper CMS-1500 claim Required fields Required if applicable Not required Not all blocks on the CMS form must be completed Refer to payer-specific guidelines Medicare Medicaid Workers Comp

Payer Top left corner Top right corner QR code Payer name Visual difference of old vs new claim form Top right corner Payer name Claim mailing address May be barcoded

1. Program Block Medicare Medicaid Tricare ChampVA Group Health Plan FECA Blk Lung Other Check the appropriate block Refer to the reverse of the form for instructions The words in (xxxx) tell you what the subscriber ID requirements Ie SS#, ID# Only one box can be checked

1a. Insured’s ID Number Medicare – Social Security number with alpha suffix (or prefix if Railroad) Medicaid – recipient ID number Tricare – sponsor’s social security number Group Health or Individual – policy ID#

2. Patient’s Name Last name, first name, middle initial Medicare – must match the name on the Medicare ID card exactly Should match the patient’s ID card No punctuation (Smith-Jones), (O’Halley)

4. Insured’s Name Enter the subscriber or policyholder’s name, if different than the patient Enter SAME if it is the patient

5. Patient Address Enter the patient’s street address No PO boxes City, State, Zip + 4 Telephone number

6. Patient Relationship to Insured Self Spouse Child Other What are some “others?”

3. Patient’s Date of Birth and Sex MMDDYY Male or Female

7. Insured’s Address If different than patient If same as patient, enter SAME

9. Other Insured’s Name Leave blank unless the claim is a secondary claim Enter the Primary payer name

10. Is Patient’s Condition Related to 10a. Employment (Current or Previous) 10b. Auto Accident PLACE (State) 10c. Other Accident Check YES or NO to indicate whether the patient’s condition is related to employment, an auto accident, or other accident. If the patient’s condition is the result of an auto accident, enter the two-letter abbreviation of the state in which the person responsible for the accident is insured.

10d. Claim codes Leave blank unless you are filing a Medicaid secondary claim Refer to Section MEDICAID SECONDARY for instruction on completing a TPL claim

11. Insured’s Group Policy or FECA Number 11. Group Number 11a. Insured date of birth 11.b Other claim id, ie property/casualty ID number 11d. Is there another health benefit plan? Yes or No If yes, you are referred back to Block 9 Why is it important to have the policy’s group number on the claim? PRICING AGENTS – price then route to patient’s/payer administrator to adjudicate claim

12. Patient or Authorized Person’s Signature “I authorize the release of information of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.” SIGNATURE ON FILE Date

13. Insured’s or Authorized Person’s Signature “I authorize payment of medical benefits to the undersigned physician or supplier for services described below.” SIGNATURE ON FILE No date

PHYSICIAN OR SUPPLIER INFORMATION

14. Date of Current Illness or Injury Required if applicable IF Block 10a, 10b, or 10c is checked YES, completing Block 14 may expedite claim processing Date of first symptom (Illness) Date of injury (Accident) Last Menstrual Period (LMP) Qualifier: Indicates which type of date is being reported May expedite claim processing by not holding up claim for medical records Why LMP? Global maternity period Claim related to pregnancy or separate from pregnancy

15. Date of Same or Similar Illness Other date relevant to patient’s illness

16. Dates Patient Unable to Work in Current Occupation Not required

17. Name of Ordering/ Referring Provider or Other Source Referring provider name Required for all Medicare, Railroad Medicare, and Medicare Advantage claims Qualifier indicates whether provider is the referring, ordering, or supervising provider The ordering provider is required for Laboratory Radiology Medical and Surgical Supplies Respiratory DME Enteral and Parenteral Therapy Durable Medical Equipment Drugs (J-Codes) Temporary K Codes Orthotics/Prosthetics Temporary Q Codes Vision Codes Ordering providers can be an MD, DO, Optometrist, Physician Assistant, Registered Nurse Practitioner, Dentist, Podiatrist, Psychologist, or Certified Nurse Midwife Medicare Ordering Providers must be an enrolled/credentialed/certified Medicare provider

18. Hospitalization Dates Related to Current Services Not required

19. Reserved for Local Use Additional claim notes Modifier -99 Indicates 3 or more modifiers for a service code North Carolina Medicaid Carolina Access # Medicare – Medical records attached to electronic claim

20. Outside Lab and Charges Not required Check NO

21. Diagnosis Codes At least one – up to 12 diagnosis codes Expanded to allow for ICD-10-CM codes Priority order Alphabetic indicators in Block 21 link to CPT codes in Block 24E Diagnosis Pointer ICD Ind(icator) identifies code as ICD-9-CM or ICD-10-CM All codes must be either ICD-9 or ICD-10; cannot mix them up Enter at least one ICD-9 code describing the patient’s condition. Up to four diagnosis codes are listed in priority order (primary condition, secondary condition, etc) based on coding. Include numeric codes, V-Codes and E-Codes Diagnosis codes are linked to specific CPT codes by their order number (SEE BLOCK 24E)

22. Resubmission Code Corrected insurance claims Medicaid Resubmission Code Numeric code to indicate Replacement Claim Void of Previous Claim Original Ref No Original ICN (Internal Control Number) Medicaid claim number

23. Prior Authorization Number Authorization number approved for service May have multiple auth numbers Date of service range Type of service provided CLIA number for in-house labs

24A. Dates of Service From – To MMDDYY One Line per service code One claim per date of service NDC Qualifier for Drug Codes In the pink-shaded area, enter the NDC Qualifier of N4 in the first 2 positions, followed by the 11-digit NDC number

24B. Place of Service Enter the 2-digit code that describes the place of service (POS) Most common in physician billing 11 Office 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Department 24 Ambulatory Surgery Center

24C. EMG – Emergency Indicator Mark this box with an “X” or “Y” if the service was an emergency service, regardless of where it was provided

24D. Procedures, Services, Supplies CPT/HCPCS Up to six lines per claim More than six requires a second claim Modifier Appends to service code Provides additional information to payer regarding service Affects payment Enter the CPT/HCPCS procedure code that identifies the service provided. If the same procedure was provided multiple times on the SAME DATE OF SERVICE, enter the procedure only once. Use the units field to indicate the number of times the service was provided on that date. CHECK WITH PAYER FOR SPECIFIC INSTRUCTIONS For some claims billed with CPT/HCPCS codes, procedure modifiers must be used to accurately identify the service provided and avoid delay or denial of payment

24E. Diagnosis Pointer Links the service provided to the diagnosis code(s) listed in Block 21 by enter the letter of the appropriate diagnosis Enter only the reference number from Block 21 (A, B, C, etc), not the diagnosis code itself May have multiple lines with one or more diagnosis Have to tell the insurance carrier which diagnosis goes with the service Examples Annual Check Up with Flu Shot 99835 V72.31 90658 V04.81 90471 V04.81 Office visit for diabetes, hypertension and flu shot 99213 250.00 401.9 90648 V04.81 90471 V04.81

24F. Charges Fee/charge for service reported per Line Units of service – enter total amount of charge for number of units reported 1 unit = $50 Billed units = 3 Total charge = $150.00 Enter the total charges for each service/procedure for the individual Line Enter the total charges for number of units billed – THE INSURANCE COMPANY WILL NOT CALCULATE YOUR CHARGE FOR YOU!!

24G. Units Enter the number of units provided Bill all units of service provided on a given date on one line Units or Days

24H. EPSDT/Family Planning Not required Early and Periodic Screening Diagnosis and Treatment Family Planning Use FP modifier for Medicaid Family-Planning recipients

24I. ID Qualifier Not required

24J. Rendering Provider ID# Rendering physician’s NPI number is reported in the white area Shaded area may include the taxonomy code, if required

25. Federal Tax ID Number Enter the tax ID number and check the box labeled “EIN” If the provider does not have a tax ID, enter the provider’s social security number and check the box labeled “SSN”

26. Patient Account Number Enter the number assigned to uniquely identify this claim in the provider’s records Cross-reference between the payer’s claim and the provider’s claim accounting or tracking system. May be Medical Record number Patient account number Claim control number This number will be referenced or linked by the payer to the claim processed

27. Accept Assignment Check YES or NO What happens if you check NO or don’t check either?

28. Total Charge Total charge for all services reported on the claim

29. Amount Paid Not required May be used if current claim is secondary and you are reporting primary payer payment DO NOT use to report patient payments!! DO NOT use to report expected copays or deductibles due from the patient!!

31. Signature and Date Signature of Physician or Supplier including degree or credentials “I certify that the statements on the reverse apply to this bill and are made a part thereof” Printed name of rendering provider Date claim was completed/printed

32. Service Facility Location Information Name and address of facility where services were provided 32a. Service Facility NPI# Facility NPI number 32b. Service Facility ID# Not required

33. Billing Provider, Name, Address, & Phone Enter the billing providers name, address, and phone number Practice name Not always the same as the rendering provider’s name 33a. Billing provider NPI# Practice or Group NPI 33b. Other ID Not required unless indicated by payer-specific guidelines