1. 1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. The Health Insurance Claim Form Chapter 21

2. 2 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Universal Claim Form: A Brief History  Originally called the HCFA-1500  First developed in 1988 by the Health Care Financing Administration (HCFA)  July 2001, HCFA was renamed the Center for Medicare and Medicaid Services (CMS) and the claim form was renamed the CMS-1500  The current version of the CMS-1500 was adopted in August 2005  As of May 2008, only the CMS-1500 (08-05) claim form may be used to submit insurance claim forms

3. 3 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Claims  Hard Copy (Paper Claims)  insurance claims submitted on paper claim forms and sent by mail to the insurance carrier  the Intelligent Character Recognition (ICR) system is used to scan documents and capture claims information directly from the CMS-1500 form  Advantages of Paper Claims  minimal start-up costs  forms are readily available  ability to attach documentation explaining unusual circumstances that might affect reimbursement  Disadvantages of Paper Claims  greater cost in time, labor  reimbursement is much slower  paper claims also require a lot of storage space

4. 4 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Claims: Rules for Hard (Paper) Claims  Rules for completing the paper CMS-1500 form in order for the insurance carriers to scan the claims using ICR  Entries should be clear and sharp; carbon copies are not acceptable.  A proportionally spaced 12-point font such as Courier, Times New Roman, or Arial works best.  All uppercase letters should be used.  All punctuation should be omitted.  The MM DD CCYY format (with a space between each set of digits) should be used for all birth dates.  All entries should be kept within their respective Block. All characters, i.e., X, Y, N, must fall completely within the designated Block.  For the following, a blank space should be substituted: Dollar signs and decimal points in charges and ICD codes Dollar signs and decimal points in charges and ICD codes Dashes preceding procedure code modifiers Dashes preceding procedure code modifiers Parentheses around telephone area codes Parentheses around telephone area codes Hyphens in Social Security numbers Hyphens in Social Security numbers Titles and other designations, such as Sr., Jr., II, or III, should be omitted unless they appear on the identification (ID) card. Titles and other designations, such as Sr., Jr., II, or III, should be omitted unless they appear on the identification (ID) card. When the charge is expressed in whole dollars, two zeros should be used in the “cents” column. When the charge is expressed in whole dollars, two zeros should be used in the “cents” column. If a typewriter is used, do not use lift-off tape, correction tape, or correction fluid. If a typewriter is used, do not use lift-off tape, correction tape, or correction fluid. Because photocopies of claims cannot be scanned, all resubmissions must be prepared using the original (red print) claim form. Because photocopies of claims cannot be scanned, all resubmissions must be prepared using the original (red print) claim form. No handwritten data (other than signatures) may be included on the forms. No handwritten data (other than signatures) may be included on the forms. Nothing should be stapled to the form. Nothing should be stapled to the form. The name and address of the insurance company should be inserted in the proper area in the top margin of the claim form. The name and address of the insurance company should be inserted in the proper area in the top margin of the claim form.

5. 5 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Claims  Electronic Claims  insurance claims that are transmitted over the Internet from the provider to the health insurance company  Advantages of Electronic Submission  processing and payments are received in less than half the time required for turnaround of paper claims  tracking reports can be sent quickly and provide vital information about the claim  Reduction in error rate

6. 6 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Electronic Claims Submission  Electronic claims can be submitted in several ways  direct billing - transmitted directly to the insurance carrier  to a claims clearinghouse - which then submits the claims to the insurance carrier  Clearinghouses typically provide additional services  Audit claims to make sure all required fields are completed and data are correct  Report the number of claims submitted and the number of errors and their specifics  Forward claims to insurance carriers that accept electronic claims (Medicare, Medicaid, Blue Cross/Blue Shield, and others) or to another clearinghouse that may hold the contracts with specific payors  Keep provider offices updated as new carriers are added to the database  Generate informative statistical reports

7. 7 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Data Gathering   Guidelines for collecting information for insurance claim preparation  Have the patient or patient’s guardian complete the Patient Registration, Release of Information, and Authorization of Benefits form(s) in full, and return them to the medical assistant.  Ask for the patient’s and insured’s drivers license and insurance card(s). If patient is a student, ask if they have a student ID, and if so, request it from the patient. If a patient has more than one insurance policy, it is important to get the name, address, group, and policy number for each company.  Photocopy the back and front of the patient’s insurance card and place the photocopy in the medical record and/or patient’s insurance file. Most medical offices also photocopy the patient’s and insured guarantor’s driver’s license or other state-certified identification card for verification of the patient’s and insured’s identity, and, where applicable, a student ID card.  Confirm the patient’s and insured’s full name, address, phone number, date of birth, and gender by comparing the Patient Registration form to the driver’s license or identification card.  Determine if someone other than the patient is the guarantor. The guarantor is the person or entity responsible for payment. The guarantor may be the patient, the insured, or a third party. If the guarantor is neither the patient nor the insured, obtain the guarantor’s address, date of birth, employer information, and the guarantor’s relationship to the patient (i.e., spouse, parent, self, or other).  Call the employer and confirm employment (optional). If the patient is insured under a Group Health Plan, Worker’s Compensation, TRICARE, and some other types of insurance, this information can be confirmed when verifying eligibility and benefits.  Confirm that the patient has signed and dated the Release of Information form.

8. 8 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Data Gathering  Guidelines for collecting information in preparation for insurance claim preparation  Confirm the insured has signed the Authorization of Benefits form. Signatures to authorize insurance billing, supplying of information to insurance companies, and acceptance of assignments of benefits (if appropriate) should be obtained from all new patients and at the beginning of each new calendar year.  Contact the insurance carrier and perform a verification of benefits and insurance coverage.  Obtain any precertification or referral authorization(s) required by the insurance carrier or payor.  Code the diagnosis(es) for the encounter using the ICD-9-CM coding manual.  Select any qualifying circumstance, physical or patient status, or other modifiers as appropriate.  Code the procedures and services rendered during the encounter using the CPT and/or HCPCS coding manual.  Select any CPT and/or HCPCS modifiers as appropriate.  Using Table 20-1 or a similar list of information to gather in preparation for insurance claim submission, confirm that all information needed is available.

9. 9 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Benefits  Verification of Eligibility and Benefits  Verified by phone calling the insurance carrier(s) for the patient calling the insurance carrier(s) for the patient confirming that the patient is covered confirming that the patient is covered obtaining a general overview of the benefits available obtaining a general overview of the benefits available confirming that the information obtained over the phone is verified by a fax or email from the insurance carrier confirming that the information obtained over the phone is verified by a fax or email from the insurance carrier  Performed electronically using the ASC X12N transaction and code sets for the request and the response using the ASC X12N transaction and code sets for the request and the response  ASC X12N 270 Health Care Eligibility Benefit Inquiry  ASC X12N 271 Health Care Eligibility Benefit Response  Preauthorization and/or Referral  If necessary, perform a preauthorization to obtain an authorization number

10. 10 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. CMS-1500  There are 33 blocks on a CMS-1500 claim form  Blocks are divided into three Sections  Section 1: Carrier Block The first section contains the address of the insurance carrier and is located at the top of the form The first section contains the address of the insurance carrier and is located at the top of the form  Section 2: Patient/Insured Section The second section contains information about the patient and insured person, and contains Boxes 1 through 13 The second section contains information about the patient and insured person, and contains Boxes 1 through 13  Section 3: Physician/Supplier Section The third section contains Boxes 14 through 33 and details physician or supplier information The third section contains Boxes 14 through 33 and details physician or supplier information

11. 11 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Completing the CMS-1500  Completing the CMS-1500 Insurance Claim Form  Block 1: Type of Insurance  Block 1a Insured’s ID Number  Block 2 Patient’s Name  Block 3 Patient’s Birth Date and Sex  Block 4 Insured’s Name  Block 5 Patient’s Address  Block 6 Patient Relationship to Insured  Block 7 Insured’s Address  Block 8 Patient Status (employment status)  Block 9 Other Insured’s Name  Block 9a Other Insured’s Policy or Group Number  Block 9b Other Insured’s Date of Birth and Sex  Block 9c Employer’s Name or School Name  Block 9d Insurance Plan or Program Name

12. 12 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Completing the CMS-1500  Blocks 10a to 10c Is Patient’s Condition Related to?  Block 10d Reserved for Local Use  Block 11 Insured’s Policy, Group, or FECA Number  Block 11a Insured’s Date of Birth, Sex  Block 11b Insured’s Employer’s Name or School Name  Block 11c Insurance Plan Name or Program Name  Block 11d Is there another Health Benefit Plan?  Block 12 Patient’s or Authorized Person’s Signature  Block 13 Insured’s or Authorized Person’s Signature  Block 14 Date of Current Illness, Injury, or Pregnancy  Block 15 Same or Similar Illness  Block 16 Dates Patient Unable to Work in Current Occupation

13. 13 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Block 17 Name of Referring Provider or Other Source  Block 17a Other ID  Block 17b NPI Number  Block 18 Hospitalization Dates Related to Current Services  Block 19 Reserved for Local Use  Block 20 Outside Laboratory and Charges  Block 21 Diagnosis or Nature of Illness or Injury  Block 22 Medicaid Resubmission  Block 23 Prior Authorization Number Completing the CMS-1500

14. 14 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Block 24A Date(s) of Service  Block 24B Place of Service  Block 24C EMG  Block 24D Procedures, Services, or Supplies  Block 24E Diagnosis Pointer  Block 24F Dollars Charges  Block 24G Days or Units  Block 24H EPSDT/Family Plan  Block 24J Rendering Provider ID Number  Block 25 Federal Tax ID Number  Block 26 Patient’s Account Number Completing the CMS-1500

15. 15 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Block 27 Accept Assignment  Block 28 Total Charge  Block 29 Amount Paid  Block 30 Balance Due  Block 31 Signature of Physician or Supplier (include degrees or credentials)  Block 32 Service Facility Location Information  Block 32a NPI Number  Block 32b If the service facility does not have an NPI number, enter the payor-assigned unique identifier of the facility and the qualifier number  Block 33 Billing Provider Information and Phone Number  Block 33a NPI Number  Box 33b Other ID Number Completing the CMS-1500

16. 16 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Reviewing Claims  Guidelines for Claims Review Before Submission  Proofread the form carefully for accuracy and completeness.  Make certain any necessary attachments are included with the completed form.  Follow office policies and guidelines for claim review and signatures.  Forward the original claim to the proper insurance carrier either by mail or electronically.  If creating a paper claim, make a copy of the completed and signed claim form for the office records.  If a noncomputer-generated insurance log is maintained, enter the appropriate information in the insurance log, and record the insurance submission information on the patient’s ledger.  The patient’s and/or insured’s name, address, and ID, group and/or policy number should be identical to the information printed on the insurance card.  Patient’s birth date and sex should correspond with the medical record.  The word “NONE” should appear in Block 11 if Medicare is the primary payor.

17. 17 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Reviewing Claims  Guidelines for Claims Review Before Submission  The referring, consulting, or ordering provider’s name and NPI number should be entered in Blocks 17 and 17a, if applicable.  Accept assignment should be checked “yes” if the physician is a participating provider (PAR) or has an agreement with the insurance carrier or payor to accept assignment.  Be sure the diagnosis is not missing or incomplete.  The diagnosis must be coded accurately using the ICD-9-CM and must correspond with the treatment.  The patient must have authorized the release of information, and Block 12 should contain a handwritten signature, the words “Signature on File,” or the acronym SOF.  The patient section (Blocks 1-13) should be completed accurately according to the guidelines of the insurance carrier.

18. 18 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Guidelines for Claims Review Before Submission  Fees for each charge must be listed individually or correctly computed if more than one day or unit is entered in Block 24G.  All required fields of the diagnosis and procedure section of the claim form (Blocks 14-24K) should be accurate and completed according to the guidelines of the third-party payor or insurance company.  The physician’s signature must be on the form.  The federal Employer Identification Number (EIN), Tax Identification Number (TIN), or Social Security number (SSN) should be double-checked to ensure accuracy.  The physician’s correct NPI number corresponding to the insurance carrier being billed should be entered in Block 24k and again in Block 33a. The provider’s PIN number, when applicable, should be entered in Block 33b, with the Qualifying number, when applicable. Reviewing Claims

19. 19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Preventing Claim Rejection  Denied or Rejected Claims  The two main reasons for denial of payment technical errors technical errors insurance policy coverage issues insurance policy coverage issues  Clean claim is a complete, accurate claim  Dingy or Dirty claim is an inaccurate or incomplete insurance claim returned for more information or correction  Rejected claim is a claim for which payment has been denied for any reason

20. 20 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Claim Status  Checking Claim Status  It is often necessary to send a “tracer” to an insurance company to determine the status of a delinquent insurance claim A tracer is typically a form letter A tracer is typically a form letter  It is accepted practice to submit the tracer a day or two after the usual turnaround time of the payor, generally 30 to 60 days  Checking claim status can also be performed electronically using the ASC X12N transaction and code sets for the request and the response ASC X12N 276 Health Care Claim Status Request ASC X12N 276 Health Care Claim Status Request ASC X12N 277 Health Care Claim Status Response ASC X12N 277 Health Care Claim Status Response

21. 21 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Claim Status  Audit Trails: electronic transactions that leave behind a path or trail as they are processed  Patient Education: the medical assistant should be able to explain confusing technical issues to patients in simple, understandable terms  Legal and Ethical Issues: the practice of medicine and the responsibilities of the medical assistant are greatly affected by the legislative process