CMS-1500 CLAIM FORM

Chapter 4


CMS-1500 CLAIM FORM



Objectives


After completing this chapter, you should be able to:


image Use the CMS-1500 claim form correctly


image Discuss the requirements for each field on the CMS-1500 claim form and correctly complete at least seven claim forms for case studies found in Appendix C and on the CD-ROM


image Explain who is responsible for supplying each piece of information and where to find it


image Demonstrate field-specific billing rules by correctly completing at least seven claim forms for case studies found in Appendix C and on the CD-ROM


image Discuss legal responsibilities related to the CMS-1500 claim form



Key Terms



ANSII format


a complex format used to send electronic claims. It is very versatile; the electronic medical records may be attached to the claim.


beneficiary


a person entitled to benefits under an insurance policy.


CMS-1500 claim form


the claim form used by physicians and other nonfacility providers to bill payors for medical charges incurred by someone covered by the medical plan.


EDI


electronic data interchange; the process used to send claims electronically.


EPSDT


Medicaid’s early periodic screening and diagnostic testing program; a preventive medicine program for certain children covered by Medicaid.


FEIN


Federal Employer Identification Number; a tax ID number issued to a business.


insured


the person entitled to benefits under an insurance policy. The insured is the policyholder, the person whose name is listed in the medical plan’s files as the owner of the policy. Some medical plans call the insured a “subscriber,” and Medicare calls the insured a “beneficiary.”


NPI


National Provider Identifier; a number that Medicare began issuing in June 2005 to replace the UPIN, PIN, and provider number systems used historically before that time. A physician will have just one number to use in every location and every state to identify who he or she is. This number may be used in blocks 17B, 24K, and sometimes 33 on on the CMS-1500 claim form for physician billing and in FL 82 and FL 83 on the UB-92 claim form for hospital and facility billing.


NSF


National Standard Format; a simpler format used to send electronic claims. New versions are issued periodically. Only the data on the claim form are transmitted electronically. Supporting documentation is sent under separate cover.


OCR


optical character recognition; a process by which a computer “reads” information that is scanned into the computer.


outside lab


a lab that bills the physician for tests the physician purchased on behalf of a patient. The physician then bills the patient’s medical plan. When an outside lab is used, the lab is identified in block No. 32 on the CMS-1500 claim form.


patient account number


a number assigned by the practice for internal identification of the patient’s financial record.


PIN (Medicare)


a practice identification number assigned to a group practice or a solo physician who has incorporated the practice. It is used in block No. 33 on the CMS-1500 claim form.


policyholder


the primary person entitled to benefits under an insurance policy, and the person whose name is listed as the owner of the policy. Some medical plans call the policyholder a “subscriber,” and Medicare calls the policyholder a “beneficiary.” On the CMS-1500 claim form, the policyholder is the “insured.”


provider number (Medicare)


a number assigned by Medicare to identify individual providers in a group and to identify solo physicians who are not incorporated. For Medicare, the NPI will replace this number. Medicare began issuing NPIs in June 2005.


SSN


Social Security number; a tax ID number issued to an individual.


subscriber


the primary person entitled to benefits under an insurance policy. The subscriber is the policyholder—the person whose name is listed in the medical plan’s files as the owner of the policy. The subscriber is the “insured” for purposes of completing a medical claim form.


UPIN (Medicare)


unique physician identifier number; used by Medicare to identify a referring physician. Medicare began replacing this number with the NPI in June 2005.



Introduction


You have learned how to speak the language of a medical office. You have learned how medical office employees function together as a team to collect billing information from patients and physicians for the medical claim form. You have learned how to design or revise office forms so you collect the correct information. Now it is time to learn how to complete and file a medical claim.


In this chapter, you will learn how to correctly complete a medical claim form for physician billing, how to find the required information, how to determine the cause of past problems, and how to avoid problems in the future. Payor-specific rules, including Medicare, are included throughout the chapter.


The compliance guidance documents issued by the Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) strongly recommend that job descriptions be used to assign accountability for specific tasks in the medical office. The OIG developed the compliance guidance documents to help various types of medical entities meet the “accountability” requirements of the Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) (HIPAA). Many of the OIG’s recommendations relate directly to billing and collections, including assigning responsibility for gathering the information for the billing and coding of medical claims. The Medicare website for medical office education, www.cms.hhs.gov/medlearn/cbts.asp, notes how accountability is typically assigned in a medical office, and that information provided the basis on which accountability is addressed in this chapter. However, please remember that each medical office decides exactly which employee positions are assigned individual accountability for each task, and it will vary from one office to another. In addition, in a small medical office, one multiskilled professional often fills numerous employee positions.


The CMS-1500 claim form, previously called the HCFA-1500 claim form, was designed for Medicare but is now used universally for physician and supplier billing. The patient is always responsible for supplying current patient demographic and medical plan information for billing, but the receptionist is usually the employee held accountable for gathering patient-supplied information and identifying all possible payors. The receptionist usually enters this information in the computer system. The computer system often generates the claim form, and it pulls information entered from the patient registration form to automatically complete the top half of the CMS-1500 claim form.


Although the patient may list payors in any order in the insurance section of the registration form, the patient is not authorized to choose which payor is listed as the primary payor on the CMS-1500 claim form. Specific rules must be followed. As you learn these rules in Chapters 8, 9, 10, and 11, you will be able to determine the primary payor from the information the patient supplies. The biller is typically held accountable for determining the primary payor, for checking to see whether additional information is required for the specific payor(s), and for meeting payor-specific preferences when evaluating and sometimes correcting the information previously entered in the computer system.


The physician (or other provider) is always responsible for supplying the diagnoses and a description of services rendered. Often this information is sent to the billing department on a superbill, but the receptionist usually enters the information from the superbill into the computer system during patient checkout procedures. The computer pulls the information entered from the superbill to automatically complete the bottom half of the claim form.


The biller is usually the employee held accountable for double-checking the accuracy of all the information placed on the CMS-1500 claim forms before the claims are sent. This may be done using the preview feature in the software, or claims may be printed on plain paper and a transparency of a blank claim can be placed on top to show the fields on the claim form. The biller uses the computer system to correct any errors that are found before the claims are sent.


As you learn the coding rules in Chapters 5, 6, and 7, you will learn how to either confirm the information supplied by the physician on the billing form (e.g., superbill, encounter form) or to convert the diagnoses and procedures listed on the billing form into the correct medical codes. You will also learn to audit the medical records by comparing the billing information listed on the superbill with the documentation in the medical records to see whether it matches. In addition, you will learn to sequence the codes correctly. Following these steps increases the likelihood that correct reimbursement will be received in a timely manner from the payor. Many practices hire certified coders to perform coding functions, and those practices typically assign accountability for the codes selected to the person who performed the coding. Other practices give the responsibility for code selection to either the biller or the physician.


When payors and government officials talk about keeping medical costs low, what they really mean is negotiating contracted payment amounts that are low (e.g., with hospitals, physicians, and other health-care providers). Government payors, private payors, and managed care payors are all very conscientious about keeping medical costs as low as possible and limiting medical fraud and abuse, and they use every means at their disposal (legal or not) to reduce payments. There have been many news reports in recent years of payor/physician contracts that contained illegal clauses, and of payors who tried to enforce the illegal clauses even when presented with legal challenges. According to contract law, illegal clauses are not legally enforceable. However, payors can try to enforce contracts that physicians have signed. It is better to find these clauses and remove the illegal clauses before the contract is signed.


When submitting a medical claim, you must address even the smallest of details, and you must be accurate. When the medical claim reaches the payor, the computer system or the assigned claims adjuster looks first for any reason not to pay the claim. If a reason to deny payment is not found, payment is authorized. Next, the computer system or the claims adjustor looks for any reason to pay the smallest amount possible. The payors are not being mean. They are merely fulfilling one of their financial responsibilities. They are obligated to pay valid claims, but they are not obligated to pay inaccurate claims. If a physician’s office sent you a bill that was not accurate, and in fact overcharged you, would you sit right down and pay it promptly without asking any questions? If you would not do it, is it reasonable to expect a payor to do it?


The explanation of benefits (EOB) or the Medicare remittance notice (MRN) that accompanies payment or denial of payment for a medical claim is supposed to explain the payment decision, but often the explanation given is very vague. An EOB may say “insufficient data” as a reason for nonpayment but not tell you which information is missing. This is because many times when information changes in one field, the requirement for information in other fields also changes. The payor usually does not know what else might be wrong. By learning claim form requirements, you will learn how to detect missing information and check for other fields that might also require changes.


Many times a minor detail, such as not answering either “yes” or “no” to a question, can cause a delay in payment. Sometimes the diagnosis and the service billed do not seem to correlate. The payor will want more information from the physician before paying the claim. Payment might be denied if the physician’s written record is not an exact match for the information submitted on the claim form. Other times, a payor might decide that the service is not covered by the medical plan or the service is not medically necessary (meaning at least one diagnosis in block No. 24E is not an adequate or an appropriate reason to perform the service on that line).


The rules for completing and submitting a claim form can vary, depending on whether you send the claim electronically or on paper. When you send a paper claim, use a barcoded “dropout red” CMS-1500 claim form. Most payors scan paper claims into their computer systems. The color of the form is called dropout red because the scanner does not read or record that color; it only reads and records the information placed in each block on the claim form. The barcode tells the payor’s computer how to line up the information so the computer can correctly record the information in the corresponding computer fields and then read it correctly using optical character recognition (OCR). Do not use correction fluid on claims that will be scanned because correction fluid smears in the scanner. Instead, use correction tape. When there is no barcode to tell the payor’s computer how to line up the information or when other OCR requirements have not been met, a claims adjustor usually must enter the claim into the payor’s computer manually, and this increases the possibility of an error occurring after the claim leaves your office.


Electronic claims are sent using national electronic data interchange (EDI) standards. Some standards are built into the claims transmission software, and others you must meet as you prepare the claim. You have the best control over claim quality when you meet EDI standards for all electronic claims and when you meet OCR requirements for all paper claims. OCR and EDI requirements, when applicable, are noted throughout the chapter.


The CMS-1500 is the universal claim form used by physicians, other providers, and suppliers to bill payors for services rendered and for supplies. The front of the claim form (Figure 4-1) contains blocks or fields that are completed to meet specific payor requirements. The back of the claim form (Figure 4-2) provides a general guideline for all medical plans, a statement of legal responsibility, and information and directions tailored for specific government medical plans.


image
FIGURE 4-1 CMS-1500 claim form, front. The CMS-1500 is the universal claim form used by physicians, other providers, and suppliers to bill payors for services rendered and for supplies. This side of the claim form contains blocks or fields that are completed to meet specific payor requirements. Note: A different claim form is used by facilities such as hospitals and surgicenters to bill payors for facility fees.

image
FIGURE 4-2 CMS-1500 claim form, back. This side of the claim form provides a general guideline for all medical plans, a statement of legal responsibility, and information and directions tailored for specific government medical plans.


Patient and Insurance Information


Every medical claim is a legal document. The top half of the CMS-1500 medical claim form is used to report patient demographic and medical plan billing information. The right-side margin of the CMS-1500 claim form has a note printed sideways that says carrier with arrows that indicate the top margin. The carrier is the primary payor. The right-side margin on the top half of the CMS-1500 claim form also says patient and insured information, printed sideways with arrows that indicate block No. 1 through block No. 13. It is the patient’s responsibility to provide the most current and accurate information for every claim that is filed on his or her behalf. Knowingly supplying false or inaccurate information is considered a federal crime (fraud), punishable by fines, imprisonment, or both.


When the scheduler faithfully gathers insurance and demographic information at the time each appointment is scheduled, every patient, even new patients, will have information on file for advance verification and for comparison to the insurance card and registration documents completed during check-in.


The receptionist is usually the employee held accountable for gathering billing information from each patient during check-in and for identifying all possible payors. It is easy to become complacent with established patients, but the receptionist must verify billing information for each encounter. Established patients can and do change insurance policies from time to time, and sometimes patients fail to pay premiums or to qualify for government programs and are dropped from coverage.


Occasionally, a patient requires treatment after a new insurance policy takes effect but before the patient receives an insurance ID card for the new plan. It is acceptable to take the insurance information verbally or in handwritten form, but you should call the insurance company to verify the ID numbers, mailing address, level of coverage, and copay amounts before the appointment or before the patient leaves the office so other payment arrangements can be made if the information is not correct. Instruct the patient to send you a copy of the front and back of the card for your files when the card does arrive.


It is the biller’s responsibility to compare the patient information gathered during check-in with the existing information already on file. When a discrepancy is noted, the biller must verify which information is correct and update the patient’s financial record. Sometimes you must call the patient to obtain current information when that step was missed during check-in.


The primary payor is the medical plan that is responsible for paying when there is no other coverage and the medical plan that pays first when there is coverage from more than one payor. A secondary payor pays second and tertiary payor pays third when there is more than one payor.


If you want to file clean claims and receive correct payments the first time, you must learn to look at each claim through the payor’s eyes. When a claim arrives at the payor, the claim editing and claim auditing processes begin immediately. The first items the claims adjustor or the payor’s computer checks are those located in the top half of the claim form. When any of the following information is incorrect, there is no obligation for payment, and the claim might be rejected. The payor wants to know:



image Was the claim sent to the correct address as listed on the patient’s insurance card? Each payor has different billing addresses for different policies. When the claim is sent to the wrong billing address for the specific policy, the payor’s computer will not recognize the patient.


image Is the person listed as insured for each payor on the claim form covered under that plan?


image Is the patient covered by each listed plan?


image Is the insurance policy current, meaning, have the premiums been paid?


image Is the correct payor identified as primary payor? If not, there is no obligation for payment until correct information is submitted. A secondary payor only pays charges remaining after the primary payor has paid. A tertiary payor only pays charges remaining after the secondary payor has paid.


image Does the demographic information for both the patient and the insured match payor records? If not, the claim will be rejected until it can be verified that the patient is covered by the plan.


Let’s take a closer look at specific claim requirements for the top half of the CMS-1500.



TOP MARGIN


Figure 4-3 shows the top margin of the CMS-1500 claim form. This is a required field. The name and mailing address of the primary payor are printed on the right half of the top margin of the CMS-1500 claim form. The left half of the top margin is reserved for the barcode.


image
FIGURE 4-3 Top margin of the CMS-1500 and block No. 1-block No. 1a.

Windowed envelopes, such as those shown in Figure 4-4, are often used to mail paper claims. The payor’s name and address show through the window as “addressee,” so the information recorded here must meet postal requirements.


image
FIGURE 4-4 Windowed envelopes are often used to mail paper claims. The payor’s name and address show through the window. (Courtesy Bibbero Systems, Inc., Petaluma, Calif 94954; 800/242-2376; www.bibberosystems.com)

The patient’s insurance card should list a mailing address for the payor. The mailing address is often located on the back of the card. This is why you must obtain a legible photocopy of both the front and back of each insurance card for each patient. If the information on the card is illegible in the photocopy, handwrite the information on the same page next to the illegible image. You also may call a patient if you cannot read the required information on the photocopy.


Sometimes a payor/physician contract changes the mailing address for claims to a particular payor or payor(s). Therefore you should check for contract requirements, if any.


Payor name and address are required in the top margin of the claim even when claims are transmitted electronically. When electronic claims arrive at a claims clearinghouse, only the claims that meet EDI requirements can be forwarded to payors electronically. The rest are dropped to paper (printed on a paper CMS-1500 claim form) at the clearinghouse, and a machine automatically folds them, stuffs them into windowed envelopes, and mails them.


Even when the payor mailing address is missing, electronic claims that drop to paper are automatically mailed. This is done by machine. A person does not usually check to see if postal requirements are valid for every one of the thousands of claims dropping to paper each day. The post office eventually returns claims with no mailing address to the clearinghouse as undeliverable mail. The clearinghouse must then investigate to find out where each claim originated—perhaps your office. Weeks can easily pass before you learn that the payor did not receive the claim. If the payor contract has a 60-day deadline for filing “clean” claims and 60 days have already passed, you can no longer expect to receive payment for that claim.



When a patient has more than one payor, the claim filed to the primary payor has “P” printed in the top left margin under “Please do not staple in this area” and above the three small boxes. Secondary claims have “S,” and tertiary claims have “T” instead of “P.” Usually computerized billing systems automatically generate this information based on the manner in which payors are identified for each patient. However, the biller should type in this detail when claims are prepared without the aid of a computer.



Payor-specific requirements:


TRICARE/CHAMPUS: When the patient lives in the United States and travels within the United States, claims are sent to the region for the patient’s home address. When the patient lives overseas, but receives medical care in the USA, the following rules apply:




block No. 1. PAYOR TYPE


Figure 4-3 shows block No. 1. This is a required field. The type of primary payor is indicated with an “X” placed in the box preceding the payor type. Valid selections are Medicare, Medicaid, CHAMPUS, CHAMPVA, Group Health Plan, FECA, and Other. The type of number required in block No. 1a is listed in parentheses under each payor type in this field.


Payor-specific requirements:


Medicare: Anytime Medicare is primary, even with Medicare Advantage plans (Medicare + Choice), Medicare should be marked in this field. Originally, Medicare Advantage claims were sent to Medicare, but now they are sent to the payor with whom the patient contracted for coverage. See Chapter 10 for further details about the Medicare Advantage programs.


Blue Cross Blue Shield: The traditional Blue Cross Blue Shield plans fall under “group health plan.”


Managed Care: Sometimes managed care HMOs and PPOs, including Blue Cross Blue Shield HMOs and PPOs, want to be listed as a “group health plan,” and sometimes they want to be listed as “other.”


Workers’ Compensation: For workers’ compensation, mark “other.”


Do not give the claims adjuster a reason to reject your claim. If you do not know the correct choice, call the payor and ask. The payor’s telephone number can be found on the patient’s insurance card. Often it is located on the back of the card, near the mailing address.


Document the phone call and the response in the patient’s financial record so you do not have to call each time you file a claim for this patient. If you keep your own payor-specific insurance notes or notebook, also record the information there.



The Black Lung program is a federal medical program that covers qualified coal miners that suffer from anthracosis, also known as “black lung,” because it is caused by coal dust in the lungs.




block No. 1a. Insured’s ID Number


Figure 4-3 shows block No. 1a. This is a required field. The patient-specific ID number for the primary payor goes in this field. The insured’s ID number is normally found on the patient’s insurance card. Sometimes it is called a member number. The payor uses this information to confirm that the patient is indeed entitled to receive benefits. Claims will not be paid without this information.


The insured is the policyholder, the person whose name is listed in the medical plan’s files as the owner of the policy. Some medical plans call the insured the “subscriber,” and Medicare calls the insured the “beneficiary.” The employee is the insured for an individual or a family medical plan obtained through an employer, and the employer is the insured for workers’ compensation.


The insured’s ID number is often, but not always, based on the insured’s Social Security number (SSN). Do not make assumptions. Check the insurance card. A notation in parenthesis under the payor type in block No. 1 tells the type of number required in block No. 1a. The number listed here must be valid for the insurance plan indicated in block No. 1 and named in block No. 11c.



If the patient is covered by a family policy, sometimes this number will be the same for all covered family members. However, this is becoming rare. More often, the insured’s ID number will vary for each covered person. For example, sometimes this number will be the policyholder’s SSN followed by a dash and “01” to designate the policyholder, “02” to designate the spouse, “03” to designate one child, “04” to designate the next child, and so on until each person covered by the policy has been given a unique insured’s ID number. The insured’s ID number is not always based on a SSN. Always get the number from the insurance card.




EDI and OCR do not recognize dashes, slashes, decimal points, and other special characters. Do not enter dashes in this box, and do not leave blank spaces unless specifically directed to do so.



Payor-specific requirements:


TRICARE/CHAMPUS: Enter the military sponsor’s military ID number.


Workers’ Compensation: Although the “insured” is the patient’s employer, enter the patient’s SSN in this field.



block No. 2. PATIENT NAME


Figure 4-5 shows block No. 2 of the CMS-1500 claim form. This is a required field. Enter the name as last name, first name, middle initial (when applicable). The patient’s name must be spelled exactly as it appears on the insurance card. Do not enter commas between last name and first name.


image
FIGURE 4-5 block No. 2-block No. 4 of the CMS-1500 claim form.

The name entered here is the name of the patient—the person who received the treatment(s) or service(s) listed on the claim form. Only one patient name may be entered on each claim form. If a parent brought two children to see the physician, and the physician looked at both of them during the same visit, a separate claim form must be submitted for each child. When you are filing a batch of claims for patients who have similar names, be very careful to verify that each piece of information is completed for the correct person.


The name entered here should be the patient’s legal name. However, if the patient has changed names, such as occurs when a woman marries, do not change the name in your records until the insurance card lists the new legal name. The name in the medical record must match the name on the claim form. If the claim is filed using the new name before the payor changes their records, the payor will not recognize the patient, and the claim will be denied. However, be sure to list the correct information in block No. 8 under marital status. Also, call the payor to see if coverage changed when the patient married. A dependent daughter who marries is no longer covered under a parent’s policy. Knowingly supplying false or inaccurate information is considered a federal crime and is punishable by fines, imprisonment, or both.



Be very careful with your record-keeping during the interval between the time a patient’s name legally changes and the time the payor recognizes the new name. Your medical office must have a record of both the old name and the new name and a method to identify that both names belong to the same person. The patient will probably call the office to schedule appointments using the new name, so you must be able to find information both ways. Remember, the old name must be listed with the current marital status on both the claim and the medical record until the new name is recognized by the payor.




block No. 3. PATIENT BIRTH DATE AND GENDER


Figure 4-5 shows block No. 3. This is a required field. If either the birth date or the gender is missing, the claim could be rejected. The information entered here is used to verify the identity of the patient.


Birth Date: Enter the patient’s date of birth with an eight-digit date.


The patient’s birth date must be earlier than any of the other dates listed on the claim, such as date of service, date of claim, date of procedure, and/or date of accident. A pregnant woman is considered to be the patient for both herself and the unborn child she is carrying.



To meet EDI and OCR requirements, use only numbers for dates, and do not enter slashes or dashes. For OCR, the date is entered as MMDDYYYY. For example, March 7, 2005, would be entered as “03072005.” For EDI, the date is entered as YYYYMMDD. For example, March 7, 2001, would be entered as “20050307.” If you use a claims clearinghouse, enter all dates using OCR guidelines and the clearinghouse will translate the dates to EDI requirements for the claims that are actually sent electronically.



Gender: select the appropriate gender code, “M” for male, “F” for female. Some procedures have gender-specific codes. For example, only a female would have a vaginal exam, and only a male would have a prostate exam. When the gender marked on the claim does not match the gender documented in payor records for the covered patient, or the gender marked on the claim does not match the gender specified for the procedure, the claim will be denied.



block No. 4. INSURED’S NAME


Figure 4-5 shows block No. 4. Enter the name of the insured individual. When the patient is the insured, this block may be left blank or you may write “same.” This block is used only when the patient is not the policyholder.



A family policy is issued to one specific person even though it provides coverage for the entire family. When an employer issues a family policy, the employee to whom the policy was issued is the named insured, and the name of the employee would be listed here when another covered family member is the patient.



Payor-specific requirements:


Medicare: Medicare requires this section to be blank except in certain situations when Medicare is the secondary payor. This field is completed only when the Medicare patient is not the policyholder for the other policy.



Workers’ Compensation: List the employer as the policyholder.


TRICARE/CHAMPUS: Enter the name of the military sponsor.



block No. 5. PATIENT ADDRESS


Figure 4-6 shows block No. 5 of the CMS-1500 claim form. This is a required field. Enter the patient’s address, including number, street, city, state, and zip code. An address is required on all claims. List the patient’s telephone number with area code.


image
FIGURE 4-6 block No. 5-block No. 8 of the CMS-1500 claim form.

The information in this field must match the information on file with the payor, or the payor will not recognize the patient, and the claim will be denied. If the patient has moved recently, call the payor to verify the address to be listed on the claim, and remind the patient to update his or her address with the payor.



When the patient lives in a nursing home or other extended-care facility, provide the facility’s address.




Some insurance companies require a telephone number. If the patient does not have one, ask the patient for the telephone number of a close friend or relative.


If the payor requires a telephone number and the patient cannot provide one, call the payor and ask for the telephone number listed in the payor’s files for the patient.


As a last resort, when the payor requires a telephone number and no other telephone number is available, list the national information number—the patient’s area code plus 555-1212.



Payor-specific requirements:


TRICARE/CHAMPUS: When the patient lives overseas but is receiving medical care in the United States, the patient’s overseas home address is used on the claim.



block No. 6. PATIENT RELATIONSHIP TO INSURED


Figure 4-6 shows block No. 6. This is a required field. The choices are “Self,” “Spouse,” “Child,” or “Other.” The information in this block tells the payor how the patient is related to the policyholder, so the payor may verify that the patient is covered by one of their policies. Claims are not paid without this information.


If the patient is the policyholder, choose “Self.” Do not expect the insurance company to assume that the patient is the insured just because the names are the same. Many parents name their children after themselves.


When you choose “Spouse,” “Child,” or “Other,” you are telling the payor that the policy is listed in another person’s name, even when the patient and the policyholder share the same name. The payor will then look to be sure block No. 4 and block No. 7 have been completed for the policyholder. If they have not, the claim will be rejected. The EOB reason code will probably say “Patient not covered” because the payor cannot verify coverage.


Even when everything else on the form is correct (including information about the insured when different from the patient), if this section is left blank, you risk a rejection. Payors receive many claim forms that have been completed incorrectly. They will not make assumptions, and they will not make a selection for you.


Payor-specific requirements:


Workers’ Compensation: Select “Other.”



block No. 7. INSURED’S ADDRESS


Figure 4-6 shows block No. 7. This field is required when block No. 4 is completed and the insured has a different address than the patient. If the insured and the patient have the same address, place “same” in this section.


This information must match payor records or the claim will be denied.



Some insurance companies require a telephone number. If the insured does not have one (or the patient does not know the insured’s telephone number), list the patient’s telephone number or list the telephone number of a close friend or relative of the insured.


If the payor requires a telephone number and the patient cannot provide one, call the payor and ask for the telephone number listed in the payor’s files for the insured.


As a last resort, when the payor requires a telephone number and no other telephone number is available, list the national information number—the patient’s area code plus 555-1212.


Payor-specific requirements:



TRICARE/CHAMPUS: Enter the home address for the military sponsor. If the patient does not know the military sponsor’s home address (as may happen after a divorce), enter the patient’s address.


Workers’ Compensation: List the employer’s address.



block No. 8. PATIENT STATUS


Figure 4-6 shows block No. 8. This block records the employment, student, and marital status of the patient.



Marital status: For marital status choose “Single,” “Married,” or “Other.” The payor checks to see if this matches the information in their records. If the patient’s marital status has changed, the patient is required by law to notify his or her medical plan. Claims are denied when the information does not match payor records.


Employed: If the patient is employed, put “X” in this box. If the patient is not employed, leave the box blank.


Student: If the patient is a student, select “Full-time” or “Part-time.”


Most insurance companies will reject a claim if both “Employed” and “Full-time student” are selected. You may select both “Employed” and “Part-time student.” This information is very important if the patient is a student older than age 18 covered under a parent’s policy. Generally, a child older than age 18 is only covered under a parent’s policy if he or she is a student or one who meets the disability requirements.



block No. 9. OTHER INSURED’S NAME


Figure 4-7 shows block No. 9 of the CMS-1500 claim form. Enter the name of the insured for the secondary policy. This block is used to identify the policyholder for the second plan. When the patient is the insured for both the primary and the secondary plans, this field is left blank.


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FIGURE 4-7 block No. 9-block No. 11d of the CMS-1500 claim form.


When a husband and a wife both have family policies issued by their respective employers, special rules apply. When the husband is the patient, his policy is always primary. When the wife is the patient, her policy is always primary. In both instances, the spouse’s plan is secondary.




When both parents’ policies cover the children, special rules apply:




Payor-specific requirements:


Medicare: Medicare requires this section to be blank unless the patient is also covered by another plan. When block No. 9 is completed, block No. 13 must be completed. When the patient is the insured for the secondary policy (as in Medigap), enter “same” in this field.


Except for Medicaid, Medigap, and specific Medicare supplemental policies, Medicare is always the secondary payor when two health plans may be billed.


Only participating Medicare physicians and suppliers may complete block No. 9 and its subdivisions for Medicare patients, and they must have an “Assignment of Benefits” from the patient for both Medicare and the other policy. For example, when a Medicare patient is also covered by a spouse’s health plan, a Medicare participating physician may complete this section when “Assignment of Benefits” is on file for both Medicare and the spouse’s health plan. In this instance, the spouse’s plan is primary and Medicare is secondary.


Nonparticipating Medicare physicians do not complete block No. 9 and its subdivisions. Medicare prohibits this because Medicare does not file crossover claims for nonparticipating physicians. Crossover claims occur when Medicare is the primary payor, and Medicare automatically forwards the claim with Medicare payment information to the secondary payor listed in block No. 9 and its subdivisions. Nonparticipating physicians file all secondary and tertiary claims themselves and include a copy of each MRN or EOB already received on the claim. They use the answer in block No. 11d (“Is there another health benefit plan?”) combined with the letters above the PICA boxes in the top left margin of the claim form as the indicators for primary, secondary, or tertiary claim status.


Medigap: Only participating Medigap physicians and suppliers may list Medigap information in block No. 9 and its subdivisions. When block No. 9 is completed, block No. 13 must be completed.


A participating Medicare physician who is also a participating Medigap physician may complete this section when “Assignment of Benefits” is on file for both Medicare and Medigap. Anytime a patient has both Medicare and Medigap, Medicare is considered primary and Medigap is secondary.


Nonparticipating Medigap physicians do not complete block No. 9 and its subdivisions because Medicare does not file crossover claims for nonparticipating physicians. Nonparticipating Medigap physicians file all secondary claims themselves and include a copy of each MRN or EOB already received on the claim. They use the answer in block No. 11d (“Is there another health benefit plan?”) combined with the letters above the PICA boxes in the top left margin of the claim form as the indicators for primary, secondary, or tertiary claim status.



block No. 9a. Other Insured’s Policy or Group Number


Figure 4-7 shows block No. 9a. This block is used to identify the secondary payor. Enter the individual or group policy number or FECA (Black Lung) number for the secondary payor. The information can be found on the insurance card for the secondary plan. If you cannot find the policy number on the insurance card, call the payor and ask them for the number. Most secondary payors require a number in this box.



To meet EDI and OCR requirements, do not enter dashes or other special characters in this box.



Payor-specific requirements:


Medicare: When Medicare is the secondary policy, enter the Medicare number here.


Medigap: The Medigap policy or group number must be preceded by the word “Medigap.” For example, if the Medigap policy number is A-123-45, it should be entered as “Medigap A12345.”




block No. 9c. Employer’s Name or School Name


Figure 4-7 shows block No. 9c. If the secondary policy is from an employer, the employer’s name is placed in this box. However, when the patient is a student who is old enough to be employed but who is covered by a parent’s policy, the school should be listed in this box.


Payor-specific requirements:


Medicare: This field may be left blank.


Medigap: Enter the claims processing address listed on the patient’s Medigap ID card. Use accepted postal abbreviations to enter an abbreviated street address, a two-letter state postal code, and a zip code.



block No. 9d. Insurance Plan or Program Name for Second Policy


Figure 4-7 shows block No. 9d. Enter the name of the secondary insurance plan or program. This information is listed on the insurance card for the secondary payor and tells the payor the exact policy to reference for this claim.


Payor-specific requirements:


Medigap: Enter the name of the Medigap payor or the unique Medigap identifier assigned by the carrier. For Medicare crossover claims, use the Medigap identifier. This identifier is usually six letters (ABCDEF).



block No. 10. PATIENT CONDITION


Figure 4-7 shows block No. 10. This section asks if the medical care reported on this claim form is necessary because of:



You must check either “yes” or “no” for each one of these. This is a very important and a frequently abused section of the claim form.


The answers to these questions often determine which insurance company is responsible for covering this care. You will save much time and aggravation by filing the claim form correctly the first time. “Yes” or “no” must be selected for each choice. Do not leave this field blank.


When “yes” is selected in this section, the date of the accident or injury must be entered in block No. 14, and E-codes describing the place and cause of the accident or injury must be entered in block No. 21. Please see Chapter 5 to learn about E-codes and the diagnosis coding guidelines for injuries.


Many times a “yes” answer to one of the questions means that the primary payor should be one of the following: workers’ compensation, an automobile policy, or another type of liability policy. When you list a liability payor in block No. 11 as the primary payor, the medical plan may be listed as the secondary payor.


When the claim is sent with a medical plan as primary payor and a “yes” is marked in one of these boxes, coding edits will alert the medical plan to the possibility of another payor, and the claim could be denied until payor responsibility is determined.


Payor-specific requirements:


Medicare: Medicare requires at least one E-code (explaining the accident) in block No. 21. Medicare may be billed as secondary payor for auto accidents and most types of liability insurance, and now the Medicare training website indicates that Medicare may be billed as secondary payor for workers’ compensation. If payment is not received in 120 days, you may request a “conditional primary payment” from Medicare. When a Medicare conditional payment is made, special rules apply. Please see Chapter 10 for details about Medicare conditional payments.


Liability Plan: When a liability plan is billed, one of the choices in this field must be marked “yes,” and payor edits will look for the date of the accident or injury in block No. 14 and an E-code describing the accident or injury in block No. 21. If any of the required information is missing or does not match payor records, the claim will be rejected.


Note: In some instances, specific medical plans want to be billed as the primary payor, with the liability plan that might be responsible listed as the secondary payor. The medical plan pays for the services initially, investigates the claim, and exercises the right of subrogation to collect from the liability plan, when applicable. TRICARE/CHAMPUS and Blue Cross Blue Shield are among the medical plans that often prefer this option.


Let’s take a closer look at each of these choices.



block No. 10a. Employment Accident


Figure 4-7 shows block No. 10a. If the medical care reported is due to a work-related incident, this box will be marked “yes.” You must contact the employer involved and follow the state-specific procedures to file for workers’ compensation.


When workers’ compensation is denied, you are usually allowed to appeal the denial. If it continues to be denied, you may then file the claim with the patient’s medical plan, attaching a copy of the denial(s). In this way, you “justify” the claim, and the medical plan is more likely to consider the claim for payment.


When an injured worker is not covered by workers’ compensation, bill the applicable liability plan as primary and place “No workers’ compensation” in block No. 19. The injured worker’s medical plan is not billed as primary unless no other policy provides coverage.

Related posts:

  1. DEVELOPING CRITICAL THINKING SKILLS: ANALYZING PROBLEMS AND MAKING DECISIONS
  2. REIMBURSEMENT SUCCESS
  3. OTHER GOVERNMENT MEDICAL PLANS
  4. HOSPITAL/FACILITY BILLING RULES

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May 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on CMS-1500 CLAIM FORM

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