1 / 34

Part 1 Filing 3 rd Party Claims

Part 1 Filing 3 rd Party Claims. Addressing: The CMS-1500 Form & Its Electronic Equivalent Diagnosis Coding. Disclaimers. This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD.

aideen
Download Presentation

Part 1 Filing 3 rd Party Claims

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Part 1Filing 3rd Party Claims Addressing: The CMS-1500 Form & Its Electronic Equivalent Diagnosis Coding

  2. Disclaimers This information was prepared by the 3rd Party Consultant to the Nebraska Optometric Association, Ed Schneider OD. To the best of his knowledge, it was current and accurate at the time it was prepared. It is not guaranteed to be error or omission free. It was prepared as general information to assist doctors and staff, and is not intended to grant rights or impose obligations.

  3. Disclaimer • The ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services. • The Nebraska Optometric Association, and its presenters, agents, consultants and staff makeno representation, warranty, or guarantee that this presentation and/or its contents are error-free or omission-free, and will bear no responsibility or liability for the results or consequences of the information contained herein.

  4. Filing Claims – Info provided • Who (patient & insured) • Why (diagnosis) • What (service provided) • When (date provided) • How Much (fees) • Where (provided) • By Whom (provider)

  5. Filing Claims –Format Used • Medical Insurance Claims • Electronic • Generally filed through a Clearinghouse • Must use HIPAA 5010 Format • Paper • CMS-1500 paper form (less than 10 FTE employees) • Routine Care Claims • Proprietary paper forms • CMS-1500 paper form • Internet direct filing

  6. CMS-1500 to Electronic Claims Crosswalk • Claim information based on CMS-1500 Claim Form • For those who file electronically, there is a WPS source that explains where to insert the CMS-1500 data items into which electronic claim data loop. • This is referred to as the CMS-1500 Electronic Claim Crosswalk, and can be found at • http://www.wpsic.com/edi/pdf/npi_1500_crosswalk.pdf

  7. CMS-1500

  8. TOP OF CMS-1500 Insurance Type

  9. TOP OF CMS-1500 Patient Demographic data

  10. TOP OF CMS-1500 Insured Person’s Data

  11. TOP OF CMS-1500 Other Insured Person’s Data

  12. TOP OF CMS-1500 Subrogation Data

  13. TOP OF CMS-1500 Other Insurance

  14. TOP OF CMS-1500 Patient Authorization to File Claim

  15. TOP OF CMS-1500 Patient Authorization to Pay to Provider (So Dr. can accept assignment)

  16. BOTTOM CMS-1500 Referring Dr. Data

  17. BOTTOM CMS-1500 Qualifying Information Example: Date assumed + date relinquished post-op care + # Post-op care days.

  18. BOTTOM CMS-1500 Diagnosis Data MORE TO COME ON THIS AREA….

  19. BOTTOM CMS-1500 Date of Service Data

  20. BOTTOM CMS-1500 Service & Materials Supplied MORE TO COME ON THIS AREA….

  21. BOTTOM CMS-1500 Charges/Fee Data

  22. BOTTOM CMS-1500 Group Practice: Providing Dr’s NPI

  23. BOTTOM CMS-1500 Provider Data

  24. Medicare Provider Manual Billing InstructionsIncluding what data in which box • CMS Medicare Claims Processing Manual Website – (chapter 26)http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf

  25. Medicare Provider Manual Billing InstructionsIncluding what data in which box

  26. Medicaid Provider Manual Billing InstructionsWhat data in which box • Payments section: • http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-03.pdf • Form CMS-1500 Instructions • http://www.hhs.state.ne.us/reg/appx/471-000-65.pdf

  27. Routine Care Claims • Companies may still use proprietary claim forms (or on-line via Internet) • Patient & Insured demographics • Policy data • Service provided • Diagnosis (refractive ICD-9-CM) • Materials provided

  28. BOTTOM CMS-1500 Diagnosis Data

  29. Diagnosis Codes • Don’t write “cataracts” or “presbyopia” • Instead, use a standard code • ICD-9-CM is standard resource for diagnosis codes • ICD-10-CM is coming soon, codes are completely different.

  30. Diagnosis Codes 1st look up in alphabetical listing

  31. Then refine in tabular listing

  32. Diagnosis Codes • An ICD-9-CM code for every eye disorders • Cataract, senile: 366.10 • E-codes for external causes • E960.0 due to unarmed fight • V-codes for other situations • V58.69 observation due to use of toxic medication • Routine Care Claims • Use ICD-9-CM Refractive codes

  33. Diagnosis Codes • ICD-9-CM is soon to be replaced by ICD-10-CM • Completely different diagnosis coding system • More comprehensive • Defines disorders more explicitly • Required on all claim by October, 2013? (2014?) • Quick Reference Guide at http://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf • More information at http://www.cms.gov/ICD10/01_Overview.asp#TopOfPage

  34. Thank You for Listening We hope this information has been helpful. Thank you for listening! See our NOA Website for more 3rd Party Educational Videos. 3rd Party Services Nebraska Optometric Association

More Related