1. 11
Physician Medical Billing

2. Key Terms and Abbreviations
assignment of benefits form
audit/edit report
billing services
birthday rule
claim attachment
clean claims
clearinghouse
CMS-1500 claim form

3. Key Terms and Abbreviations
coordination of benefits (COB)
dirty claim
durable medical equipment (DME) number
electronic claims, electronic media claims (EMCs)
encryption
employer identification number (EIN)

4. Key Terms and Abbreviations
facility provider number (FPN)
form locators
group provider number (GPN)
guarantor
National Provider Identifier (NPI) number
optical character recognition (OCR)
patient information form

5. Key Terms and Abbreviations
policyholder
provider identification number (PIN)
release of information form
secondary insurance
state license number
superbills
supplemental insurance
tax identification number (TIN)

6. Key Terms and Abbreviations
UB-04 claim form
verification of benefits (VOB) form

7. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
11.1: Differentiate and complete medical claim forms accurately, both manually and electronically.
11.2: Define claim form parts, sections, and required information.

8. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
11.3: Exhibit the ability to complete claim forms without omitting information.
11.4: Understand the common reasons why claim forms are delayed or rejected and submit a claim without payer rejection.

9. Chapter Objectives
After completing this lecture, you should be able to complete the following learning objectives:
11.5: File a secondary claim.

10. Manual and Electronic Medical Claim Forms
11.1: Differentiate and complete medical claim forms accurately, both manually and electronically.

11. 11.1: Manual and Electronic Medical Claim Forms
Insurance Claims
A claim is also called an encounter record.
Insurance claims can be submitted to payers in paper format (manually) or electronically.

12. 11.1: Manual and Electronic Medical Claim Forms
Insurance Claims
Electronic claims, also known as electronic media claims (EMCs), are submitted through a clearinghouse, billing service, or directly to the carrier. These contain electronic signatures.

13. 11.1: Manual and Electronic Medical Claim Forms
Insurance Claims
Advantages of electronic claim submission include lower administrative costs, reduced claim rejection, and faster payment.

14. 11.1: Manual and Electronic Medical Claim Forms
CMS-1500 Claim Form
The CMS-1500 Health Insurance Claim Form was developed by the Centers for Medicare and Medicaid Services.
The CMS-1500 is mandatory for Medicare claims and has become the standard claim form used by private and government payers.

15. 11.1: Manual and Electronic Medical Claim Forms
CMS-1500 Claim Form
The paper CMS-1500 form is printed in red ink to be recognizable to optical character recognition (OCR) scanners.

16. 11.1: Manual and Electronic Medical Claim Forms
Completion of Claim Forms
Specific guidelines exist for accurately completing the CMS-1500 form.
Government programs (Medicare, Medicaid, TRICARE, CHAMPVA, and workers’ compensation) have claim submission rules specific to their program.

17. 11.1: Manual and Electronic Medical Claim Forms
Completion of Claim Forms
State insurance regulations and local guidelines also vary, so the medical office specialist must be familiar with federal, state, and local rules as well as with guidelines from private insurance carriers and government programs.

18. 11.1: Manual and Electronic Medical Claim Forms
Completion of Claim Forms
Claim attachments are additional documentation sent to a payer to substantiate the medical necessity of a claim.

19. 11.2: Define claim form parts, sections, and required information.
Claim Forms
11.2: Define claim form parts, sections, and required information.

20. 11.2: Claim Forms Parts of the CMS-1500 Claim Form
In this textbook, each numbered field or item to be completed on the CMS-1500 is called a form locator.
The upper portion of the form contains patient and insured information. It consists of 13 form locators (numbered 1–13) with 11 data elements and 2 signature fields.

21. 11.2: Claim Forms Parts of the CMS-1500 Claim Form
The lower portion of the form contains physician or supplier information. It consists of 20 form locators (numbered 14–33) with 19 data elements and 1 signature field.

22. Figure 11.10a -- CMS-1500 claim form
11.2: Claim Forms
Figure 11.10a -- CMS-1500 claim form

23. Figure 11.10a -- CMS-1500 claim form
11.2: Claim Forms
Figure 11.10a -- CMS-1500 claim form

24. Figure 11.10a -- CMS-1500 claim form
11.2: Claim Forms
Figure 11.10a -- CMS-1500 claim form

25. Figure 11.10b -- Draft CMS-1500 form, version 02/12.
11.2: Claim Forms
Figure 11.10b -- Draft CMS-1500 form, version 02/12.

26. Figure 11.10b -- Draft CMS-1500 form, version 02/12.
11.2: Claim Forms
Figure 11.10b -- Draft CMS-1500 form, version 02/12.

27. Table 11.1 -- CMS-1500 Abbreviations>
11.2: Claim Forms
Table CMS-1500 Abbreviations>

28. Table 11.1 -- CMS-1500 Abbreviations>
11.2: Claim Forms
Table CMS-1500 Abbreviations>

29. Completed Claim Form
11.3: Exhibit the ability to complete claim forms without omitting information.

30. Figure 11.11 -- Practice Exercise 11.1 CMS-1500 form.
11.3: Completed Claim Form
Figure Practice Exercise 11.1 CMS-1500 form.

31. 11.3: Completed Claim Form CMS-1500 Required Information
1 Type of Insurance
Type of government or private insurance.
1a Insured ID Number
ID number as shown on the insurance card.

32. 11.3: Completed Claim Form CMS-1500 Required Information
2 Patient’s Name
Must match name shown on the insurance card.
3 Patient’s Date of Birth/Sex
Enter date and check correct box.

33. 11.3: Completed Claim Form CMS-1500 Required Information
4 Insured’s Name
If patient is the insured, enter “Same.”
5 Patient’s Address
Enter complete address.
6 Patient’s Relationship to the Insured
Check correct box.

34. 11.3: Completed Claim Form CMS-1500 Required Information
7 Insured’s Address
If patient is the insured, leave blank.
8 Patient Status
Check correct box for marital and employment status.

35. 11.3: Completed Claim Form CMS-1500 Required Information
9 Other Insured’s Name
Enter name if there is a holder of another policy that may cover the patient. If no secondary policy applies, leave blank.

36. 11.3: Completed Claim Form CMS-1500 Required Information
9a Other Insured’s Policy or Group Number
If a secondary policy applies, enter the number as it appears on the insurance card.

37. 11.3: Completed Claim Form CMS-1500 Required Information
9b Other Insured’s Date of Birth/Sex
9c Employer’s Name or School Name (for insured)
9d Insurance Plan Name or Program Name
Enter name of secondary insurance plan.

38. 11.3: Completed Claim Form CMS-1500 Required Information
10a/b/c Is Patient’s Condition Related to:
Check correct box.
10d Reserved for Local Use
Use this per specific carrier guidelines.
11 Insured’s Policy Group or FECA Number
Enter group number as it appears on the insurance card.

39. 11.3: Completed Claim Form CMS-1500 Required Information
11a Insured’s Date of Birth/Sex
11b Employer’s Name or School Name (for insured)
11c Insurance Plan Name or Program Name (for primary plan)
11d Is There Another Health Benefit Plan?
Check correct box.

40. 11.3: Completed Claim Form CMS-1500 Required Information
12 Patient or Authorized Person’s Signature

41. 11.3: Completed Claim Form CMS-1500 Required Information
13 Insured’s or Authorized Person’s Signature
Signature of patient or insured authorizes direct payment to the provider or supplier.
14 Date of Current Illness, Injury, Pregnancy

42. 11.3: Completed Claim Form CMS-1500 Required Information
15 If Patient Has Had Same or Similar Illness
Enter first date of treatment for same/similar illness.
16 Dates Patient Unable to Work in Current Occupation

43. 11.3: Completed Claim Form CMS-1500 Required Information
17 Name of Referring Physician or Other Source
Enter physician first and last name and credentials; leave blank if no referring physician. 

44. 11.3: Completed Claim Form CMS-1500 Required Information
17a ID Number of Referring Physician
Enter ID number and two-character qualifier.
17b NPI Number
Enter NPI number of referring physician.

45. 11.3: Completed Claim Form CMS-1500 Required Information
18 Hospitalization Dates Related to Current Services
19 Reserved for Local Use
Use this per specific carrier guidelines.
20 Outside Lab
Check correct box; if “Yes,” enter amount.

46. 11.3: Completed Claim Form CMS-1500 Required Information
21 Diagnosis or Nature of Illness or Injury
Enter ICD-9 or ICD-10 codes.
22 Medicaid Resubmission Code
Use for Medicaid claims, if applicable.
23 Prior Authorization Number
Use when required by the carrier.

47. 11.3: Completed Claim Form CMS-1500 Required Information
24A Dates of Service 
24B Place of Service
Enter code for location.
24C EMG (Emergency)
Enter Y for “Yes” if emergency service; leave blank for “No.” 

48. 11.3: Completed Claim Form CMS-1500 Required Information
24D Procedures, Services, or Supplies
Enter CPT or HCPCS codes and any necessary modifiers.
24E Diagnosis Pointer
Indicates the number (1, 2, 3, and/or 4) of the diagnosis code shown in form locator 21.

49. 11.3: Completed Claim Form CMS-1500 Required Information 24F Charges
Enter amount for each CPT or HCPCS code.
24G Days or Units
24H EPSDT Family Plan
Enter Y for “Yes” if services provided through Medicaid EPSDT (plus any required codes) or N for “No.”

50. 11.3: Completed Claim Form CMS-1500 Required Information
24I ID Qualifier
Enter qualifier for non-NPI number, if applicable.
24J Rendering Provider
Enter non-NPI and NPI numbers.
25 Federal Tax ID Number

51. 11.3: Completed Claim Form CMS-1500 Required Information
26 Patient’s Account Number
Enter account number assigned by the medical facility.
27 Accept Assignment?
Check correct box.
28 Total Charge
Enter amount.

52. 11.3: Completed Claim Form CMS-1500 Required Information
29 Amount Paid
If amount was paid by a primary insurer, this is used in submitting a claim to a secondary insurer.
30 Balance Due
Amount is total charge (form locator 28) less any amounts paid (form locator 29).

53. 11.3: Completed Claim Form CMS-1500 Required Information
31 Signature of Physician or Supplier Including Degrees or Credentials
Signature and date signed. May use “SOF” for “Signature on File.”

54. 11.3: Completed Claim Form CMS-1500 Required Information
32 Name and Address of Facility Where Services Were Rendered
32a NPI Number
32b Other ID Number
Enter non-NPI number and qualifier.
33 Billing Provider Info and Phone Number

55. 11.3: Completed Claim Form CMS-1500 Required Information
33a NPI Number
33b Other ID Number
Enter non-NPI number and qualifier.

56. Rejected Claims
11.4: Understand the common reasons why claim forms are delayed or rejected and submit a claim without payer rejection.

57. 11.4: Rejected Claims Common Reasons for Delays or Rejections
Claim submitted to secondary insurer instead of primary insurer
Missing information on patient/insured portion of claim form
Missing information on physician/supplier portion of claim form

58. 11.4: Rejected Claims Common Reasons for Delays or Rejections
Numbers are transposed
Signatures are missing
Incorrect gender ID shown so that diagnosis or procedure codes are not consistent with gender
Dates entered in an inconsistent format

59. 11.4: Rejected Claims Common Reasons for Delays or Rejections
Missing or incorrect place of service
Errors in diagnosis or procedure codes
Itemized charges unequal to total amount shown

60. 11.5: File a secondary claim.

61. 11.5: Secondary Claim Types of Coverage
Primary insurance: the first policy or plan to provide coverage, such as group plan through an employer
Secondary insurance: additional policy or plan that covers an individual, such as coverage through a spouse’s plan

62. 11.5: Secondary Claim Types of Coverage
Supplemental insurance: limited coverage of partial expenses, such as Medigap policies

63. 11.5: Secondary Claim Filing Secondary Claims
Coordination of benefits (COB) occurs when a patient is covered by more than one policy or plan.
With COB, the total benefits paid by all policies cannot exceed 100% of charges.

64. 11.5: Secondary Claim Filing Secondary Claims
Insurance carriers communicate with each other regarding payments and denials.

65. 11.5: Secondary Claim Filing Secondary Claims
Various standards are used to determine which policy is designated as primary coverage, including length of time in effect, employment or retiree status, dependant status, and other factors.

66. 11.5: Secondary Claim Filing Secondary Claims
A copy of the primary carrier’s EOB must be submitted with a secondary claim.
Prior authorization and referral numbers may still be required for secondary claims.