Insurance Claim Forms

7


Insurance Claim Forms



Objectives


After completing this chapter, readers should be able to:


image Read various forms of documentation to obtain coding information.


image Use a patient information sheet.


image Use physician identification numbers.


image Complete CMS-1500 claim forms.


image Define coding and pricing relationships.


KEY TERMS





































































































Term Definition
Batching A deferred or delayed processing method for inputting data for retrieval at a later date.
Beneficiary In the Medicare program, the person who is eligible to receive a specified payment for either coverage related to illness or injury or for death benefits.
Bundling Combining lesser services with a major service in order for one charge to include the variety of services.
CCI Correct Coding Initiative. Bundling edits created by CMS to combine various component items with a major service or procedure.
CMS-1500 A paper claim form submitted to an insurance company to provide billing information regarding patient services.
COB Coordination of Benefits. A clause that has been written into a health insurance policy stating that the primary insurance will take into account benefits payable by a secondary carrier. Prevents overpayment of the charges billed to the patient.
Component Billing Billing for each item or service provided to a patient in accordance with insurance carriers’ policies.
Covered Entities Health care providers, health plans, and health care clearinghouses.
DMERC Durable medical equipment regional carrier.
EDI Electronic Data Interchange. Computer-to-computer transfer of data between a provider of services and an insurance company or claims-processing clearinghouse.
Encounter Form Document to record information regarding services provided to a patient; used for billing purposes. Also referred to as a superbill or fee slip.
EPSDT
FECA		 Early and Periodic Screening, Diagnosis, and Treatment. A Medicaid preventive medical examination.
Federal Employees’ Compensation Act. A program administered by the Office of Workers’ Compensation Programs (OWCP), U.S. Department of Labor (DOL). This program decides whether you qualify for medical treatment and compensation under this act.
Fee Slip Also referred to as a superbill or patient encounter form. A form used to track service information.
Global Period Specific time frames assigned to a code by an insurance company before additional payment will be made following a surgical procedure.
Global Procedures Major surgical procedures that typically have a follow-up period of 30, 60, 90, or 120 days, which must elapse before you may begin to bill the patient for services related to the original procedure.
Health Care Clearinghouse Company that translates electronic transactions between the standard formats and code sets required under HIPAA and nonstandard formats and code sets.
Health Care Provider Any person who or organization that furnishes, bills, or is paid for health care in the normal course of business.
Health Plans An individual or group plan that provides or pays for the cost of medical care.
NPI National Provider Identifier. Number assigned to hospitals, physicians, nursing homes, and other health care providers that contains alphanumeric characters (e.g., E3E30KL74-6).
Ordering Physician The physician who orders nonphysician services, such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or DME for the patient.
POS Place of Service. This term refers to the physical location where services are provided to a patient (e.g., office, inpatient hospital).
Providers Service providers; for example, physicians, hospitals, pharmacies, nursing homes, DME suppliers, dentists, optometrists, and chiropractors.
Ranking Codes Listing services in their order of importance by dates of service and values. Codes are usually ranked by value from the highest charge to the lowest charge.
Referring Physician The physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Relative Value Unit A method to calculate fees for services. A unit is translated into a dollar value using a conversion factor or dollar multiplier. Assigned value is generally based on three factors: physician work component, overhead practice expense, and malpractice insurance.
Suspended File Report A listing of claims that have incorrect information such as a posting error or missing information to process the claim.
Timely Filing Clause The amount of time allowed by an insurance company for a claim to be submitted for payment from the date of the service.
TOS Type of Service. This refers to the services provided to a patient (e.g., evaluation and management services, surgery, x-rays).
Unbundling Services Listing services or procedures as separate billable components. Although this practice may generate more revenue, it is often an incorrect reporting technique that could result in an insurance company auditing a practice or asking for refunds of paid monies.
Unit Count A means to report the number of times a service was provided on the same date of service to the same patient (e.g., removal of 15 lesions).
UPIN Unique Personal Identification Number. A number assigned to each covered provider in the Medicare program to identify the provider who performed the billed service(s).



HIPAA and Electronic Claim Submission


With the implementation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, new standards now exist for claim submission, and almost all physician practices are included under the HIPAA standards. In the past, offices had the option of filing Medicare claims using a paper claim form (CMS-1500) or filing claims electronically. The new HIPAA regulations require the electronic submission of claims to Medicare if the provider is a covered entity under HIPAA.


A provider is considered a covered entity if the provider submits electronic transactions to any payer or the provider submits paper claims to Medicare and has 10 or more employees. If a practice meets at least one of these criteria, then the provider must be HIPAA-compliant and must submit claims electronically to Medicare.


A practice is not considered a covered entity if the provider has fewer than 10 employees and submits only paper claims to Medicare or if the provider does not send claims to Medicare, but instead only submits paper claims to other insurance carriers. If a practice meets at least one of these criteria, then the provider is not required to submit electronic claims to Medicare.



Coding Tip


Commercial insurance carriers might not require claims to be submitted electronically. However, if a practice, third-party biller, or clearinghouse does submit any electronic claims to any carrier, those claims must be submitted using HIPAA standards.


HIPAA also affects business associates, such as software billing vendors and third-party billing services that do business with a covered entity. Through agreements with these associates, health care providers are responsible for making sure that these companies produce HIPAA-compliant transactions.



Standards for Code Sets


Code sets are the allowable codes that anyone could use when submitting an insurance claim. To be compliant, all health care organizations must use and accept the code set systems required under HIPAA to document different medical conditions, procedures, or supplies. To comply with the HIPAA regulations, billers and coders must use the following standard code sets:



Currently, there is no standard for nonretail pharmacy transactions, including medications and biologicals.


These codes have already become a standard in the health care industry, and use of these codes is now simply mandated by HIPAA.



Standards for Electronic Claims


HIPAA standard code sets are used in conjunction with the standards for electronic transactions. When a patient comes in for an office visit, his or her confidential information is put into the practice’s management system. Codes are assigned to the diagnosis and related procedures, as discussed in Chapters 1 and 2.


When claims are generated for electronic submission, all the collected data are compiled into a HIPAA standard transaction. Providers, clearinghouses, and insurance payers all recognize these standards. To cover the entire life of the insurance claim, there are eight standard transaction functions for electronic submission, as follows:




The 837P


A standard transaction is submitted as an electronic file that has medical data compiled in a specific format. For an electronic insurance claim from a physician’s office, this format is called the 837P and replaces the paper claim, or CMS-1500. This is an electronic data set and not a paper form. The provider cannot print out the 837P, unlike the CMS-1500. A crosswalk between the 837P and the CMS-1500 is included in this chapter, after the discussion of the paper claim form (Table 7-1).



TABLE 7-1


Comparison of CMS-1500 and 837P









































































































































































































































































































































































































































































































































































































































Ref. No. on CMS CMS-1500 Box No. CMS-1500 Box Name 837P Data Element No. 837P Data Element Name
1 1 Government program 66 Identification code qualifier
2 1a Insured ID number 67 Subscriber’s primary identifier
3-6 2 Patient’s name (last, first, middle initial) 1035 Patient’s last name
1036 Patient’s first name
1037 Patient middle name
1039 Patient’s name suffix
7 3 Patient’s date of birth 1251 Patient’s date of birth
8 3 Sex 1068 Patient’s gender code
9-12 4 Insured’s name (L, F, MI) 1035 Patient’s last name
1037 Patient’s first name
1039 Patient’s middle name
13-14 5 Patient’s address 166 Patient’s address line
166 Patient’s address line
15 5 City 19 Patient’s city name
16 5 State 156 Patient’s state code
17 5 Zip 116 Patient’s postal zone or zip code
18 5 Telephone number — Not used in 837P
19-20 6 Patient’s relationship to insured (e.g., self, spouse) 1069 Individual’s relationship code
21-22 7 Insured’s address 166 Subscriber’s address line
166 Subscriber’s address line
23 7 City 19 Subscriber’s city name
24 7 State 156 State code
25 7 Zip code 116 Subscriber’s postal zone or zip code
26 7 Telephone number — Not used in 837P
27-31 8 Patient’s status (e.g., single, married) 1069 Individual’s relationship code
8 Other 1069 Individual’s relationship code
8 Employed — Not used in 837P
8 Full-time student — Not used in 837P
8 Part-time student — Not used in 837P
32-35 9 Other insured’s name (L, F, MI) 1035 Other insured’s last name
1036 Other insured’s first name
1037 Other insured’s middle name
1039 Other insured’s name suffix
36 9a Other insured’s policy or group number 93 Other insured’s group name
37 9b Other insured’s date of birth 1251 Other insured’s birth date
38 9b Other insured’s sex 1068 Other insured’s gender code
39 9c Employer’s name or school name — Not used in 837P
40 9d Insurance plan name or program name 93 Other insured’s group name
41 10 Is patient’s condition related to:   Related causes information:
42 10a Employment (current or previous) 1362 Related causes code
43 10b Auto accident 1362 Related causes code
44 10b Place (state) 156 Auto accident state or province code
45 10c Other accident 1362 Related causes code
46 11 Insured’s policy group or FECA number    
47 11a Insured’s date of birth 1251 Subscriber’s birth date
48 11a Sex 1068 Subscriber’s gender code
49 11b Employer name or school name — Not used in 837P
50 11c Insurance plan name or program name 93 Other insured group name
51 11d Is there another health benefit plan? 98 Entity identifier code
52-53 12 Patient’s or authorized person’s signature (and date) 1363 Release of information code
54 13 Insured’s or authorized person’s signature 1351 Patient’s signature source code
55-57 14 Date of current: illness, 1251 Initial treatment date
injury, 1251 Accident date
pregnancy (LMP) 1251 LMP
58 15 If patient has had same or similar illness, give first date 1251 Similar illness or symptom date
59 16 Dates patient unable to work in current occupation: From MM/DD/YY 1251 Last worked date
60 16 To MM/DD/YY 1251 Work return date
61 17 Name of referring physician or other source    
62 17a ID number of referring physician    
63 18 Hospitalization dates related to current services: From MM/DD/YY 1251 Related hospitalization
64 18 To MM/DD/YY 1251 Related hospitalization discharge date
65 19 Reserved for local use    
66 20 Outside lab?    
67 20 $ Charges    
68 21 Diagnosis or nature of illness or injury, 1 1271 Diagnosis code
69 21 2 1271 Diagnosis code
70 21 3 1271 Diagnosis code
71 21 4 1271 Diagnosis code
72 22 Medicaid resubmission code — Not used in 837P
73 22 Original ref. no. 127 Claim’s original reference number
74 23 Prior authorization number 127 Prior authorization number
75 24A Dates of service: From MM/DD/YY 1251 Order date
76 24A To MM/DD/YY 1251 Order date
77 24B Place of service 1331 Place of service code
78 24C Type of service — Not used in 837P
79 24D Procedures, services, or supplies CPT/HCPCS 234 Procedure code
80-81 24D Modifier 1339 Procedure modifier
1339 Procedure modifier
1339 Procedure modifier
82-85 24E Diagnosis code 1328 Diagnosis code pointer
86 24F $ charges 782 Line-item charge amount
87 24G Days or units 380 Service unit count
88 24H EPSDT family plan 1366 Special program indicator
89 24I EMG 1073 Emergency indicator
90 24J COB    
91 24K Reserved for local use 127 Rendering provider’s secondary identifier
92 25 Federal tax ID number 67 Rendering provider’s identifier
93 25 SSN, EIN 66 Identification code qualifier
94 26 Patient’s account no. 1028 Patient’s account number
95 27 Accept assignment 1359 Medicare assignment code
96 28 Total charge 782 Total claim charge amount
97 29 Amount paid 782 Total claim charge amount
98 30 Balance due 782 Patient’s amount paid
99-100 31 Signature of physician or supplier (and date) 1073 Provider or supplier signature indicator
101-106; 108-115 32 Name and address of facility where services were rendered 1035 Laboratory or facility name
166 Laboratory or facility address line
166
19 Laboratory or facility
156 address line
116 Laboratory or facility city
OR Laboratory or facility state
1036 or province code
1035 Laboratory or facility postal zone or zip code
  Submitter’s first name
1036 Billing provider’s last name or organizational name
166 Billing provider’s first name
166 Billing provider’s address line
19 Billing provider’s address line
156 Billing provider’s city name
116 Billing provider’s state or province code
  Billing provider’s postal zone or zip code
116-122 33 Physicians’ suppliers billing name, address, zip code, & telephone number 10351036 Billing provider’s last or organizational name Billing provider’s first name
166 Billing provider’s address line
166 Billing provider’s address line
19 Billing provider’s city name
156 Billing provider’s state or province code
116 Billing provider’s postal zone or zip code
123 33 PIN# 127 Billing provider’s additional identifier
124 33 GRP# 67 Billing provider’s identifier

Related posts:

  1. Putting it All Together
  2. Accounts Receivable
  3. Diagnostic Coding: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
  4. Service and Procedural Coding: Current Procedural Terminology (CPT)

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Dec 10, 2016 | Posted by in GENERAL SURGERY | Comments Off on Insurance Claim Forms

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