Health Care Claim Preparation & Transmission

1. Health Care Claim Preparation & Transmission Chapter 8 OT 232 OT 232 Ch 8 lecture 1

2. Introduction to Health Care Claims • HIPAA X12 837 Health Care Claim or Equivalent Form • HIPAA-mandated electronic transaction • Often called “837 claim” or “HIPAA claim” • CMS-1500 is the paper version • Can only use if less than 10 full time employees and no electronic transactions • Payers may NOT require providers to make changes or additions to the 837 claim form • Payers MAY, however, dictate how the form is filled out • National Uniform Claim Committee... • NUCC • Determines the content of the 2 claim forms and provides updates • www.nucc.org OT 232 Ch 8 lecture 1

3. Completing the CMS-1500 Claim • Carrier block • For name and address of payer • Blank 3rd line if not needed • No punctuation except for 9 digit zip • Patient Information • Identifies the patient, the insured, the health plan, etc. • IN 1 – Type of Insurance • “Group Health Plan” is not a company or plan name, but means the patient has a ‘group’ policy through an employer, etc., as opposed to an individual or government plan • “Other” is marked if the patient has an individual commercial plan, is a member of an HMO, or the claim is for an automobile accident, liability or worker’s comp. OT 232 Ch 8 lecture 1

4. Completing the CMS-1500 Claim (cont’d) • IN 1a • ID number that appears on the insurance card of the person who holds the policy • IN 2 • Patient’s name • Not always the same as 1a • EXACTLY as it appears on insurance card • IN 3 • Patient’s DOB & Gender • Enter all 4 digits for year despite “YY” on form • IN 4 • Insured’s Name • Full name of person who holds policy • Follow instructions!! Some policies require the word “same” in the box if the insured is also the patient, others want it left blank OT 232 Ch 8 lecture 1

5. Completing the CMS-1500 Claim (cont’d) • IN 5 • Patient’s address • Use permanent address • IN 6 • Patient’s relationship to insured • Child • Minor defined by policy • Other • Employee, ward – check policy • IN 7 • Insured’s address • In most cases, ‘same’ can be entered • IN 8 • Patient’s status • Important for determination of liability and coordination of benefits OT 232 Ch 8 lecture 1

6. Completing the CMS-1500 Claim (cont’d) • INs 9 through 9d • Only used if there is a secondary policy that covers the patient • Leave blank if none • INs 10a through c • Patient Condition Related to… • An ‘x’ is going to indicate that another insurance may be primary over the patient’s • IN 10d • Reserved for Local Use • Varies by plan • Commonly used to indicate “Attachments” • IN 11 • Insured’s Policy Group or FECA number • Federal Employees’ Compensation Act OT 232 Ch 8 lecture 1

7. Completing the CMS-1500 Claim (cont’d) • INs 11a through c • To be filled in if the insured is different than the patient • IN 11d • Indicates a secondary policy • If ‘yes’, then 9 should be filled out! • IN 12 • Patient’s or Authorized Person’s Signature • For TPO • IN 13 • Insured or Authorized Person’s Signature OT 232 Ch 8 lecture 1

8. Completing the CMS-1500 Claim (cont’d) • Physician or Supplier Information • Identifies provider, describes services performed, etc. • IN 14 • Date of Current Illness or Injury or Pregnancy • Date illness began, of injury, or last menstrual period (LMP) • IN 15 • If Patient Has Had Same or Similar Illness • Often left blank • Previous child is NOT a similar illness! • IN 16 • Dates Patient Unable to Work in Current Occupation • May indicate employment-related insurance coverage OT 232 Ch 8 lecture 1

9. Completing the CMS-1500 Claim (cont’d) • IN 17 • Name of Referring Physician or Other Source • INs 17a & b • ID Number of Referring Physician (split field) • 17a • Non-NPI (‘other ID’ number) • Qualifier • 2 digit indicating what the number represents • Table 8.1, page 252 • Number itself • 17b • NPI number • HIPAA National Provider Identifier • IN 18 • Hospitalization Dates Related to Current Services OT 232 Ch 8 lecture 1

10. Completing the CMS-1500 Claim (cont’d) • IN 19 • Reserved for Local Use • Another ‘flex’ box; check with payer for instructions • IN 20 • Outside Lab? $Charges • ‘yes’ if service was outsourced and now want to bill patient • Entering the amount is tricky! • Enter the amount right-aligned to the vertical line with no decimal or $. Use 00 if no cents. • $576.00 = 57600 • Can only bill for one outside service on each claim OT 232 Ch 8 lecture 1

11. Completing the CMS-1500 Claim (cont’d) • IN 21 • Diagnosis • List ICD9 codes DIRECTLY RELATED TO THE PROCEDURES BEING BILLED FOR • Enter the primary diagnosis first • Can list up to 4 • If +4, will have to split the claim with some procedures & diagnoses on another • IN 22 • Medicaid Resubmission • Left blank on all claims EXCEPT for Medicaid plans • Only to be used when resubmitting a claim or encounter OT 232 Ch 8 lecture 1

12. Completing the CMS-1500 Claim (cont’d) • IN 23 • Prior Authorization Number • Used to enter the payer’s authorization number for procedures and diagnostic tests that require preauthorization • Section 24 • Service Line Information • Only 6 lines to bill for • Top, shaded part is for additional info • IN 24A • Dates of Service • If just one day, use the FROM box • If you want to ‘group’ charges for several days, everything on the line – procedure, PoS, charges & providers – must be identical and the services must have been performed on consecutive days • IN24B • Place of Service • Appendix B, page 637 OT 232 Ch 8 lecture 1

13. Completing the CMS-1500 Claim (cont’d) • IN 24C • Some payers require a “Y” for ‘emergency situations (severe, life-threatening, potentially disabling, etc.) • Leave blank if no • Book says enter “N”, but NUCC… • National Uniform Claim Committee • …says to leave blank • This is not related to an emergency room visit, which would be POS 23 • IN 24D • Procedures, Services or Suppliers • Procedure code in effect on the date of service OT 232 Ch 8 lecture 1

14. Completing the CMS-1500 Claim (cont’d) • IN 24E • Diagnosis Pointer • Is the connection between the diagnosis and the treatment • Get info from IN 21 • IN 24F • $ Charges • Total billed charges for the service • If no charge… • Capitated or global • …enter 00 • If for multiple units, enter total charge • IN 24G • Days or Units • If days, reference 24A • In 24H • EPSDT Family Plan • Used for referral codes in some Medicaid plans OT 232 Ch 8 lecture 1

15. Completing the CMS-1500 Claim (cont’d) • INs 24I & J • ID for the rendering doctor IF it is not the same as the provider • If NPI, enter in 24J and leave 24I blank • If not an NPI, (remember 17a & b?) the qualifier goes in 24I and the corresponding id number in 24J • IN 25 • Federal Tax ID Number • Physician or supplier • IN 26 • Patient’s Account Number • One given to patient by provider • IN 27 • ‘Yes’ if provider agrees to take allowed amount as payment in full and NOT balance bill OT 232 Ch 8 lecture 1

16. Completing the CMS-1500 Claim (cont’d) • IN 28 • Total of all charges on claim • No dollar signs or commas • If 2 pages, note ‘continued’ • IN 29 • Amount paid by patient for covered services • copay or toward deductible • Amount received from primary insurance • IN 30 • Balance bill • IN 30 • Signature of Physician or Supplier w/Degrees or Credentials • Can use “SOF” OT 232 Ch 8 lecture 1

17. Completing the CMS-1500 Claim (cont’d) • IN 32 • Service Facility Location Information • Used for information if different than IN33 • Used for providers of diagnostic tests or radiology services • IN 33 • Provider’s billing info • Taxonomy codes • Another form of id that stands for a physician’s specialty • Used also if pay can be affected • Appendix A, page 633 • Awesome summary for CMS-1500, page 262-3 OT 232 Ch 8 lecture 1