Chapter 7 The Paper Claim: CMS-1500 (08-05) Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 Learning Objectives  Discuss the history of the Health Insurance Claim Form (CMS-1500 [08-05]).  State when the CMS-1500 (08-05) claim form may or may not be used.  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 reasons why claims are rejected.

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Learning Objectives (cont’d)  Describe basic guidelines for submitting insurance claims.  Explain procedures that will minimize the number of insurance forms returned because of improper completion.  Identify techniques required for optically scanned insurance claims.  Demonstrate the ability to complete the CMS-1500 (08-05) claim form accurately for federal, state, and private payer insurance contracts using current basic guidelines.

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Chapter 7 Lesson 7.1 Lesson 7.1

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. History of the Claims Process  Standard form created in  AMA approved a “universal claim form” in  Originally called Health Insurance Claim Form (HCFA-1500)  Now called CMS-1500 (08-05)  Revised form made available for optical scanning in  Revised form for NPI inclusion made available in 2005.

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Reasons for Abstracting From Medical Records  To complete insurance claim forms  When sending a letter to justify a health insurance claim after professional services are rendered  When a patient applies for life, mortgage, or health insurance

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Insurance Application Form  Part I: filled out by insurance agent during interview with client  Part II: filled out by prospective insured  Part III: filled out by physician during office visit

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Abstracting Examples

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Abstracting Examples (cont’d.)

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Basic Guidelines for Submitting a Claim  Individual insurance  Group insurance  Secondary insurance

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Common Reasons for Claim Delay or Rejection  Claim submitted to the secondary insurer instead of the primary insurer.  Information missing on patient portion of the claim form.  Patient’s insurance number is incorrect or transposed.  Patient’s name and insured’s name are entered as the same when the patient is a dependent.  Failure to indicate whether patient’s condition is related to employment or an “other” type of accident.  Patient’s signature is missing.  Physician’s signature is missing.

16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Chapter 7 Lesson 7.2

17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Optical Scanning Do’s and Dont’s  DO: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons.  DO: use original claim forms printed in red ink; photocopies17 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.

18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Optical Scanning Do’s and Dont’s (cont’d.)  DON’T: allow characters to touch lines.  DON’T: use script, slant, minifont, or italicized fonts or expanded, compressed, bold, or proportional print.  DON’T: hand write 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.

19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CMS-1500 Claim Form Instructions Top of Form

20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CMS-1500 Claim Form Instructions Block 1

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40Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CMS-1500 Claim Form Instructions Block 24B

41Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. CMS-1500 Claim Form Instructions Block 24B (cont’d.)

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49Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Insurance Program Template 1

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