Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. The Health Insurance Claim Form Chapter 20

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 2 This chapter will examine: Differences between paper claims and electronic claims Guidelines for completing the CMS-1500 form Completing each of the blocks of the CMS-1500 form Differences between clean and dirty claims Methods of preventing claim rejection Checking claim status

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 3 Universal Claim Form CMS-1500 Claim Form Revised 08/05 Used for most claims submitted to insurance companies

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 4 Types of Claims Hard copies – Physically printed and mailed to insurance companies Electronic claims – Submitted via electronic media What are the advantages and disadvantages of each???

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 5 Advantages and Disadvantages of Electronic Billing

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 6 Electronic Claims Processing Reduces the time required for reimbursement Can reduce error rates by 1% to 2% Shortens payment cycle

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 7 National Provider Identifier All allied health providers of service will be assigned one provider number. Uniform, national number replaces the many numbers used by the various providers. SSN, EIN, and TIN must still be used for tax and income reporting purposes.

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 8 Data Gathering Guidelines Photocopy the insurance ID card, back and front. Obtain demographic information about the patient. Obtain information on both policies if the patient has more than one. Get information about the insured if he or she is different from the patient. Obtain needed signatures for permission to bill and accept payment directly from the insurance company.

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 9 Assignment of Insurance Benefits

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 10 Verification of Eligibility and Benefits Call the insurance company to verify benefits. Obtain a general overview of covered items.

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 11 CMS-1500 Health Insurance Claim Form Standardized form used by most insurance carriers. Recently revised slightly to include the NPI. The 08/05 version must be in use by all providers after April 1, Contains three sections – Address of carrier – Patient information – Provider information, including diagnosis and procedure codes

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 12 Completing an Insurance Claim Form See Form on p. 383 Follow Procedure 20.1 – Kinn’s pp

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 13 Preventing Denied or Rejected Claims Claims without any significant errors of any type are called “clean claims” Claims with incorrect, missing, or insufficient data are called “dirty claims” Always review form carefully for completeness and correction before submission Always follow up on denied or rejected claims to discover if a simple fix is appropriate.

Copyright © 2008, 2005, by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 14 Checking Claim Status Periodically check to see what claims have not been paid. The accepted practice is to send a “tracer” – a form letter asking the insurance company about the status of an unpaid claim – one to two days after the usual turnaround time of the payor, generally days Contact the carrier to determine the issue with the claim. Provide more information as needed. Continue follow-up efforts.