Health Care Claim Preparation & Transmission

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