Medical Assistance Chapter 18 Cms 1500 Health Insurance Claim Form

Front 1

History of the Claim Form

Back 1

*

Front 2

Payor Requirements

Back 2

*Each third party has different requirements in claim for completion
*Familiarization with third parties requirements will maximize reimbursement
*Guidelines can be obtained from the carrier
*Clearinghouses are utilized to assist in processing

Front 3

Verification of Eligibility

Back 3

*Providers office contacts patient's insurance company to verify eligibility of coverage and benefits
*Allows for faster processing of patients services knowing correct insurance and benefit coverage
*Assists in patient education of insurance coverage

Front 4

Paper Claims

Back 4

*Advantages:
-Accepted by most insurance companies
-Documentation can be attached if necessary
-Forms are easily available
*Disadvantages:
-Postage cost
-Large storage area
-Slower reimbursement
-Follow up and reimbursemission can be slower and more costly

Front 5

Electronic Claims

Back 5

*

Front 6

Electronic Claim Processing

Back 6

*837P(HIPAA Health Care Claim:Professional)-the electronic format of the insurance claim
*Carrier Direct-claims are submitted directly to the carrier
*Clearinghouse-a centralized facility that processes claims electronically to various insurance companies

Front 7

Dividing the Claim

Back 7

*The top half of the CMS 1500 claim is related to patient information


*The bottom half of the CMS 1500 claim is related to provider services and billing information

Front 8

Signatures

Back 8

*Patient must sign:
-Releases of medical information(CMS 1500 Box 12)
-Assignment of benefits for payment to be released to provider(CMS 1500 Box 13)

*Provider
-Has signed a participating contract with the third party

Front 9

Numeric Identifiers

Back 9

*UPIN(Unique Provider Identification Number)-assigned by fiscal intermediaries for provider identification
*NPI(National Identifier Information)-10 digit lifetime number, will replace the UPIN and PIN for Medicare
*PIN(Provider Identification Number)-assigned by carriers for use on claim submission

*These are used by the IRS to identify a business for income tax reporting
-SSN(Social Security Nuber)
-EIN(Employer Identification Number)
-TIN(Federal Tax Identification Number)

Front 10

Place of Service Codes

Back 10

*These codes identify where services were provided
*Complete list can be found in front of CPT book
*Commonly used POS codes:
-11 Doctor's office
-21 Inpatient Hospital
-22 Outpatient Hospital
-31 Skilled Nursing Facility
-32 Nursing Facility(long term)

Front 11

OCR Guidelines

Back 11

*Optical Character Recognition scanners
*CMS 1500 form is printed in red ink
*The scanner had a red bulb to permit the preprinted portion of the form to disappear allowing the typed print to be excepted by the computer
*Specific guidelines should be followed precisely to facilitate OCR scanning

Front 12

Rules for Completion

Back 12

*Use all upper case letters
*Omit all punctuation
*Use 8 digit form for date
*X's must be in their respective boxes
*Use a blank space for $,-,()
*Omit titles(Jr,Sr) unless they appear on insurance card
*Express whole dollars using two zero's in "cents" column
*Never use correction tape or fluid
*Photocopies cannot be scanned, must resubmit original
*Do not handwrite on the forms
*Do not staple anything to the form

Front 13

CMS 1500 Universal Claim Form

Back 13

*Complete name and adress of Third Party Payer

*Box 1
-Check the appropriate box(only1)
*Box 2
-patients name
*Box 3
-Date of birth must be in 8 digit format
*Box 4
-If patient and insured are same person, enter"SAME"
*Box 5
-patients address
*Box 6
-patient relationship to insured
*Box 7
-insured's address
*Box 8
-

Front 14

Clean Claims

Back 14

*not all boxes are gonna be completed for each insurance company
*no missing data or errors, has been filed in a timely manner, has passed all of the edits, noaddtional work has to be filed by the biller
*when it comes back it is paid

Front 15

Rejected Claim

Back 15

Claim has been submitted and rejected by third party
*Third party may give a code to determine reason for rejection
*A claim that has been returned from the insurance company with a code represents a claim that has been rejected.
*Claim must be corrected by Biller prior to resubmitting

Front 16

Denied Claim

Back 16

*Claim has been denied by third party
-Services not covered under policy
-Ineligible service
-Applied to the deductible
-No coverage on date of service

*Claim is not resubmitted, but forwarded to patient for payment

Front 17

Dirty Claims

Back 17

*is submitted with errors and may require manual processing
*third party can actually pinned or suspend teh claim for a period of time
*claim could be rejected or paid depending on the status
*the biller may resolve the error to speed up the payment process by contacting the insurance company on a regular follow-up or calling to find out the particular status is on the claim

Front 18

Dingy Claims

Back 18

*These claim problems are the result of the Fiscal Intermediary(FI)
*They are unable to process a claim due to a system problem
*Claims are put on hold until necessary changes to system are made and claim can be processed

Front 19

Incomplete Claims

Back 19

*it requires more information
*rejected by a third party
*claim can be recollected and resubmitted and needs to be done so in a timely basis

Front 20

Invalid Claims

Back 20

*Claim has illogical or incorrect information(Provider# doesn't match, pt's sex doesn't correlate with procedure, date of birth doesn't make sense for patient)

*Claim is rejected by third party

*Claim is corrected and resubmitted by the Biller

Front 21

Pending Claim

Back 21

*The third party has suspended this claim for some reason(information request from patient)

*These claims eventually may be paid or denied

Front 22

Audit Trails

Back 22

*is for electronic transactions-leaves behind a trail or path of information as to when and where the document was actul sent, who processed the information
*helps to process the insurance or agents reports and to follow-up on claims

Front 23

Checking on Claim Status

Back 23

*Claims that are outstanding may require some investigative work

*Contact the insurance company directly

*Use claim tracking iption on insurance company website

Front 24

Claims Follow Up

Back 24

*very vital to the practice-need to do a follow up routine for the process to happen
*track the claims once they have been submitted and critcal for the financial stability of our offices