1. The Paper Claim: CMS-1500 (08-05)
Chapter 7
The Paper Claim: CMS-1500 (08-05)
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2. 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 (08-05)
Revised form made available for optical scanning in 1990.
Revised form for NPI inclusion made available in 2005.
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.)
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3. Types of Claims Paper claim Electronic 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)
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4. 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).
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5. 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).
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6. 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
Discuss legal issues of properly abstracting information from the patient’s medical records. (There may be legal guidelines to follow with patient information, such as disclosing HIV status or previous conditions. HIPAA has requirements for this type of disclosure.)
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7. 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
Explain how fees are handled during the application process. (Fees are required before completion of the form or payment may not be received. Payment may be included with the request for information.)
Refer to Figures 7-1 and 7-2 on the Evolve learning Web site for examples of the form.
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8. Abstracting Examples
Fig. 7-1A (p. 211) shows a sample chart note showing important information to read through and abstract for insurance claim completion.
Point out the main areas of the note to students.
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9. Abstracting Examples (cont’d.)
Fig. 7-1B (p. 211) shows the location of abstracted information on a CMS-1500 insurance claim form in OCR format.
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10. Basic Guidelines for Submitting a Claim
Individual insurance
Group insurance
Secondary insurance
Define the terms listed on the slide. (Individual insurance is a private insurance plan; group insurance is usually through an employer, with the patient being a member of the group; secondary insurance is when two insurance policies exist for the patient.)
Explain how individual, group, and secondary insurance each should be handled.
Describe dual coverage.
Explain how consecutive dates are handled on the form.
How are “no charge” services handled?
Explain what the physicians’ identification numbers are and what they are used for.
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11. 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)
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12. 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.
Ask students to list other common reasons. (Answers will vary.)
Discuss how each of these reasons for rejection can be avoided. (See pp of the textbook for explanation.)
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13. 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; photocopies13 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)
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14. 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.
Explain why these items are incorrect, and refer students to the previous slide or the textbook for the correct methods.
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15. CMS-1500 Claim Form Instructions Top of Form
See p. 221
The next several slides include selected blocks from the form and what information should be entered for certain carriers.
Leave the top area of the claim blank, for information that will be printed during the initial processing stage.
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16. CMS-1500 Claim Form Instructions Block 1
See pp
Medicaid: Remind students to check to see if a patient receives Medicaid.
TRICARE and CHAMPVA: Remind students to also check for these benefit systems on patient forms.
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17. CMS-1500 Claim Form Instructions Block 1app
TRICARE: If patient and sponsor are the same, provide patient’s SSN.
CHAMPVA: Use the Veterans Affairs file number without prefix or suffix.
Workers’ compensation: Use the patient’s SSN here only if there is no claim number or you can’t find a policy number for the employer.
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18. CMS-1500 Claim Form Instructions Block 4pp
For Blocks 2 and 3: Enter the name(s) as shown on the identification card. Do not use nicknames, abbreviations, or commas. The patient’s age must correlate with the diagnosis (newborn, pediatric, maternity, adult, etc.) (pp ).
Medicaid: Refer to Medicaid guidelines for this block.
TRICARE: Enter sponsor’s full name, not nicknames. Don’t fill in this block if Block 6 is marked “self.”
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19. CMS-1500 Claim Form Instructions Block 7
pp. 227
Block 5: Punctuation is not necessary in the address. For TRICARE and CHAMPVA, enter an actual address, not an APO/FPO (p. 225).
Block 6: Check “Other” for unmarried domestic partners (p. 226).
TRICARE and CHAMPVA: If sponsor and patient are different, enter sponsor info here.
Workers’ comp: Enter the employer’s address here.
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20. CMS-1500 Claim Form Instructions Block 9
See p. 229
TRICARE and CHAMPVA: Follow instructions for Medicaid. Blocks 11a through 11d should be used to report any other health insurance that the patient owns.
Workers’ comp: Leave blank. If case has not been declared workers’ comp, put in info on other insurance.
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21. CMS-1500 Claim Form Instructions Block 9a
See p. 230
Private payers, TRICARE, CHAMPVA: Enter policy or group number for secondary (or other) insurance for patient.
Medicaid and workers’ comp: Leave blank.
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22. CMS-1500 Claim Form Instructions Block 9c
See pp
Private payers, TRICARE, and CHAMPVA: Enter name of secondary insurance held by someone other than patient in this box.
Medicaid and workers’ comp: Leave blank.
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23. CMS-1500 Claim Form Instructions Block 9d
See p. 232
Private payer: Enter name of secondary insurance plan or program.
Medicaid and workers’ comp: Leave blank.
CHAMPVA: Same as TRICARE.
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24. CMS-1500 Claim Form Instructions Block 10d
See p. 235
Block 10a: All payers require a yes or no answer here (p. 233).
Block 10b: “Yes” could indicate a third-party liability case or the use of liability insurance (pp ).
Private payers, Medicare, and workers’ comp: Leave blank.
Medicare: Leave blank. Follow Medicaid guidelines as necessary.
TRICARE and CHAMPVA: Leave blank unless you have special guidelines.
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25. CMS-1500 Claim Form Instructions Block 11
See p. 236
Private payers, Medicaid, TRICARE, and workers’ comp: Leave blank.
CHAMPVA: Enter the three-digit number of the VA station that issued the ID card.
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26. CMS-1500 Claim Form Instructions Block 11b
See pp
Private payers: If primary policy is a group plan, list info here if submitting to secondary insurance.
Medicaid: Leave blank.
TRICARE and CHAMPVA: List sponsor’s branch of the service (use abbreviations).
Workers’ comp: If patient works for large corporation, list local branch or office here.
Block 11c: Leave blank in most cases. Enter “TRICARE,” for TRICARE. MSP requires a PAYER ID number. Follow MSP guidelines. (pp )
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27. CMS-1500 Claim Form Instructions Block 12
See pp
Medicaid and workers’ comp: Leave blank.
CHAMPVA: Use TRICARE guidelines.
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28. CMS-1500 Claim Form Instructions Block 13
See pp
Private payers: Signature on File (SOF) may be used here. If benefits are assigned, patient needs to sign this box.
For all others, leave blank.
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29. CMS-1500 Claim Form Instructions Block 14
See pp
Medicaid: Leave blank.
CHAMPVA: Use TRICARE rules.
Workers’ comp: Enter first date of injury or accident.
Block 15: Leave blank for Medicaid, Medicare. Enter 8-digit date (if applicable) for private payers, TRICARE, and CHAMPVA (pp ).
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30. CMS-1500 Claim Form Instructions Block 16
See pp
Medicaid: Leave blank.
TRICARE and CHAMPVA: Use Medicare rules.
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31. CMS-1500 Claim Form Instructions Block 17
See pp
Private payers, Medicaid, and workers’ comp: Enter name and degree of physician.
TRICARE and CHAMPVA: Enter name, degree, and address of referring provider. Attached DD Form 2161 if referred from MTF.
Box 17a: Enter referring physician’s NPI number for private payers, Medicaid, or Medicare. Enter state late license number for TRICARE and CHAMPVA. Leave blank for workers’ comp. (p. 246)
Box 17b: Enter physician’s NPI for ALL payers (p. 246).
Box 18: Complete this block if the service is due to an inpatient hospitalization (p. 247).
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32. CMS-1500 Claim Form Instructions Block 19
See pp
Medicare: This block is usually reserved for local use, but Medicare allows other uses under very specific rules.
Medicaid, TRICARE, and CHAMPVA: Usually reserved for local use.
Workers’ comp: Leave blank.
Box 20: For private payers, Medicare, TRICARE, CHAMPVA, and worker’s comp, check “yes” if tests were performed outside the physician’s office. Check “no” if the test were performed in the office. For Medicaid, always check “no,” because outside laboratories must bill directly. (p. 249)
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33. CMS-1500 Claim Form Instructions Block 21
See p. 250
Enter up to four diagnostic codes in this box.
Block 22: can be left blank, unless needed for Medicare/Medicaid (pp ).
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34. CMS-1500 Claim Form Instructions Block 23
See pp
Private payers and Medicaid: Enter peer review organization (PRO) 10-digit authorization code.
TRICARE and CHAMPVA: Use 10-digit preauthorization or precertification number.
Workers’ comp: Leave blank.
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35. CMS-1500 Claim Form Instructions Block 24A
See pp
Private payer and workers’ comp: Add month, day, and year for each procedure without spaces in eight-digit numbers.
Medicaid and Medicare: Use guidelines for workers’ comp but do not allow date ranges.
TRICARE and CHAMPVA: Refer to workers’ comp guidelines.
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36. CMS-1500 Claim Form Instructions Block 24B
See pp
All payers: List appropriate place of service (POS) code, shown on next slide.
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37. CMS-1500 Claim Form Instructions Block 24B (cont’d.)
Fig. 7-2 (p. 255).
All payers: List appropriate place of service (POS) code.
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38. CMS-1500 Claim Form Instructions Block 24C
See p. 256
All payers: List type of service (TOS) code in this block from list on next slide.
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39. CMS-1500 Claim Form Instructions Block 24D
See pp
Private payers, Medicaid, TRICARE, and CHAMPVA: Enter appropriate CPT/HCPCS and modifiers for each provided service.
Worker’s comp: Enter appropriate RVS codes and modifiers.
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40. CMS-1500 Claim Form Instructions Block 24E
See pp
Medicaid: Refer to Medicare guidelines.
TRICARE and CHAMPVA: Enter the diagnosis reference number to relate the service to the diagnosis.
Worker’s comp: A maximum of four diagnosis pointers may be referenced. Place commas between the numbers.
Block 24F: For private payers, enter the fee for each listed service (pp ).
Block 24G: Enter the number of days or units that apply to each line of service. Follow Medicare guidelines for TRICARE, CHAMPVA, and Worker’s Comp. For Medicaid, each service must be listed on separate lines (pp ).
Block 24H: Leave blank, except for Medicaid (enter “E” for EPSDT services or “F” for family planning services) (pp ).
Block 24I: Enter ID qualifier IC, if the provider does not have an NPI (pp ).
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41. CMS-1500 Claim Form Instructions Block 24J
All payers: Enter the NPI of the rendering physician in the lower portion.
Block 25: For all payers, enter the physician or supplier’s federal tax ID number (EIN or SSN). Medicaid cases may not require a tax ID (p. 264).
Block 26: For all payers, enter the patient’s account number, as assigned by the physician’s accounting system (pp ).
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42. CMS-1500 Claim Form Instructions Block 27
See pp
Private payers: Check whether or not the physician accepts assignment payments.
Medicaid, TRICARE, and CHAMPVA: Check the “yes” box.
Workers’ comp: Leave blank.
Block 28: For all payers, enter total charges for services listed in Block 24E. Multiply by units listed in Block 24G, if necessary (p. 266).
Block 29: For private payer and Medicare, enter only the amount paid for charges. For Medicaid, enter only the payment by a third-party payer (not Medicare). For TRICARE/CHAMPVA, enter only the amount paid by other carrier. Leave blank for workers’ comp. (pp )
Block 30: For Medicare, leave blank. For all other payers, enter balance due (pp ).
Block 31: For all payers, fill in the information and complete the signature, using an approved method (p. 268).
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43. CMS-1500 Claim Form Instructions Block 32
See p. 269
Enter only the name, address and zip code in the box.
Additional entries require separate claim forms.
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44. CMS-1500 Claim Form Instructions Block 33
See p. 269
The NPI is now required in this box for all payers.
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45. Insurance Program Template 1
CMS-1500 claim form illustrating private insurance with no secondary coverage.
This is the front side of the scannable (red ink) form.
Go through the important sections on the form with the class.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-3 [p. 272]).
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46. Insurance Program Template 2
Back of a CMS-1500 claim form.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-4 [p. 273]).
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47. Insurance Program Template 3
CMS-1500 claim form illustrating Medicaid with no secondary coverage. Note all the screened blocks of information that do not need to be filled in.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-5 [p. 274]).
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48. Insurance Program Template 4
CMS-1500 claim form illustrating Medicare with no secondary coverage. Note that the physician is accepting assignment on this claim.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-6 [p. 275]).
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49. Insurance Program Template 5
CMS-1500 claim form illustrating a Medicare/Medicaid crossover claim.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-7 [p. 276]).
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50. Insurance Program Template 6
CMS-1500 claim form illustrating Medicare primary and Medigap secondary coverage.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-8 [p. 277]).
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51. Insurance Program Template 7
CMS-1500 claim form illustrating private insurance with Medicare as secondary coverage.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig. 7-9 [p. 278]).
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52. Insurance Program Template 8
CMS-1500 claim form illustrating TRICARE coverage.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig [p. 279]).
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53. Insurance Program Template 9
CMS-1500 claim form illustrating CHAMPVA with no secondary coverage.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig [p. 280]).
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54. Insurance Program Template 10
CMS-1500 claim form illustrating workers’ compensation coverage.
This is only the top half of the form. Students can follow along in the textbook to see the entire form (Fig [p. 281]).
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