Monday, May 31, 2010

Medical billing CMS 1500 - hint & tips to complete claim

Required Fields – Professional Claims - CMS1500 (08-05)

CMS1500 FL #            Description of Information Required

1a Patient’s ID Number
2 Patient’s Name, as it appears on identification card
3 Patient’s Date of Birth (mm/dd/ccyy) and Sex
4 Subscriber’s Name—if same as patient, enter SAME.
5 Patient’s address—if different from subscriber’s, complete item 7
9-9d Other insurance information—if applicable. DOB must be in mm/dd/ccyy format.
10a-c If services are related to patient’s employment, auto accident or other accident, please complete. Otherwise leave blank.
11a-c Subscriber’s Insurance Group Number, Subscriber’s DOB (mm/dd/ccyy), Subscriber’s Sex
11d “Yes/No”—If “yes”, complete Item 9.
14 Date of onset of current illness or injury. (Use LMP for pregnancy)
17 Name of referring physician—required for lab and radiology claims only
17a Shaded area—Legacy qualifier / legacy number of referring physician (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
17b NPI of referring physician
18 Admission and discharge date if services were rendered in a hospital
19 Use to communicate information for which there is no other field designated; e.g., name of
provider for whom this provider is covering; multiple modifier information, etc., when applicable.
21 Diagnosis, ICD-9-CM to the highest level of specificity
23 Prior Authorization and/or Referral codes if applicable
24a Date of service—if only one day, please enter same date in each field
24b Place of service (as established by Medicare)
24d Procedure code using CPT4 or HCPCS codes with modifiers if applicable

Please Note: Shaded areas above Boxes 24a-d are for additional information related to the CPT/HCPC (e.g., NDC #, DME description when an unspecified HCPCS code is submitted.

24e Enter 1, 2, 3, or 4 to indicate specific ICD-9-CM code treated as indicated in Box 21. Use only
one reference number for each line item.
24f Enter the charge for each listed service, as normally billed by your office. Do not enter $0.00 for
capitated claims.
24g Number of days or units (unless included in the procedure description); report units of supplies, anesthesia minutes, oxygen volume, or multiple visits.
24i shaded Legacy ID qualifier (legacy qualifiers—1G for UPIN; G2 for MHP ID; 1C for PIN)
24j shaded Legacy ID number
24j NPI number
25 Federal Tax ID Number—Please indicate either SSN or EIN
26 Patient Account Number—For reference, if needed.
28 Enter the sum of the line item charges.
31 Name/legible signature of the provider of service, with degree or credentials
32 Name and address of facility where services were rendered
33 Pay to information
33a NPI of provider of services
33b Legacy qualifier and identifier (legacy qualifiers—G for UPIN; G2 for InsuranceProvider ID; 1C for PIN)

completing CMS 1500 instruction - Field 1 - 13

Tips for Completing the CMS-1500 Claim Form

Member Information (Fields 1-13)

Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

Field Number : 1a
Field Description : Insured's ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.

Field Number : 2
Field Description : Patient's name
Data Type : Required
Instructions :  Enter the patient's last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.

Field Number :  3
Field Description : Patient's birth date and gender
Data Type : Required
Instructions : Enter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.



Field Number : 4
Field Description : Insured's name
Data Type : Required
Instructions : Enter the insured's full last name, first name and middle initial. If the insured has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name.

Field Number : 5
Field Description : Patient's address, city, state, zip code and telephone number
Data Type : Required
Instructions :Enter the patient's mailing address and telephone number. On the first line, enter the street address (apartment number or Post Office Box number); the second line, the city and state; the third line, the ZIP code and phone number.

NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.



Field Number : 6
Field Description : Patient's relationship to the insured
Data Type : Required
Instructions : Check the appropriate box for the patient’s relationship to the insured when item 4 is completed. Remember that the patient’s relationship to the insured is not always “self”.



Field Number : 7
Field Description : Insured's address, city, state, zip code and telephone number
Data Type : Required
Instructions : Enter the insured's address (apartment/PO box number, street, city, state, zip code and telephone number with area code). When the address is the same as the patient’s enter the word “same”. Complete this item only when items 4 and 11 are completed.

NOTE: Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). When entering a none-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number.


Field Number : 8
Field Description : Patient status
Data Type : Required
Instructions : Check the appropriate box for the patient’s marital status and whether employed or a student.


Field Number : 9
Field Description : Other insured's name
Data Type : Conditional
Instructions : Required if Field 11d is marked "yes" or if there is other insurance involved with the reimbursement of this claim. Enter the name (last name, first name, middle initial) of the person who is insured under other payer.


Field Number :  9a
Field Description : Other insured's policy or group number
Data Type : Conditional
Instructions : Required if Field 11d is marked "yes" or if there is other insurance involved with the reimbursement of this claim. Enter the other insured's policy or group number or the insured's identification number.

Field Number : 9b
Field Description : Other insured's date of birth
Data Type : Conditional
Instructions : Required if Field 11d is marked "yes" or if there is other insurance involved with the reimbursement of this claim. Enter the eight-digit date of birth in MM/DD/CCYY format and enter an "X" to indicate the sex of the other insured. Only one box can be marked. If gender is unknown, leave blank.

Field Number : 9c
Field Description : Other insured's employer's name or school name
Data Type : Conditional
Instructions : Required if Field 11d is marked "yes" or if there is other insurance involved with the reimbursement of this claim. Enter the other insured's employer's name or school.

Field Number : 9d
Field Description : Other insured's insurance plan name or program name
Data Type : Conditional
Instructions : Required if Field 11d is marked "yes" or if there is other insurance involved with the reimbursement of this claim. Enter the other insured's insurance company or program name.

Field Number :  10a - c
Field Description : Is the patient’s condition related to:
• Employment?
• Auto accident?
• Other accident?
Data Type : Required
Instructions : Place an "X" in the box indicating whether or not the condition for which the patient is being treated is related to current or previous employment, an automobile accident or any other accident. Enter an "X" in either the YES or NO box for each question.

NOTE: The state postal code must be shown if “yes” is marked in 10b for “auto accident”. Any item marked yes indicates there may be other applicable insurance coverage that would be primary such as automobile liability insurance. Primary insurance information must then be shown in item 11.

Field Number : 10d
Field Description :  Reserved for local use
Data Type : Not required
Instructions : Please leave blank.


Field Number : 11
Field Description : Insured’s policy group or FECA number
Data Type : Optional
Instructions : Enter the Insured's policy or group number as it appears on the insured’s health care identification card.

Field Number : 11a
Field Description : Insured's date of birth and sex
Data Type : Conditional
Instructions : Required if the patient is not the insured. Enter the insured’s eight-digit birth date in the MMDDCCYY format and sex if different from item 3.

Field Number : 11b
Field Description : Employer name or school name
Data Type : Conditional
Instructions : Enter the insured’s employer's name, if applicable. If the insured is eligible by virtue of employment or covered under a policy as a student, enter the employer or school name.

Field Number : 11c
Field Description : Insurance plan name or program name
Data Type : Conditional
Instructions : Enter the insured's insurance company or program name.

Field Number : 11d
Field Description : Is there another health benefit plan?
Data Type : Required
Instructions : Place an "X" in the box indicating whether there may be other insurance involved in the reimbursement of this claim.

Field Number : 12
Field Description : Patient's or authorized person's signature (Medicaid/other information release)
Data Type : Conditional
Instructions :  The patient must sign and date the claim if authorizing the release of medical information. If "signature on file" is indicated, the provider must maintain a signed release form or CMS-1500 (formally HCFA 1500).
The patient’s signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier, when the provider of service or supplier accepts assignment on the claim.


Field Number : 13
Field Description : Insured’s or authorized person’s signature
Data Type : Conditional
Instructions : The signature in this item authorizes payment of benefits to the physician or supplier. Signature on file, SOF, or the legal signature are acceptable. If there is no signature on file leave this item blank or enter “no signature on file”.

Tips for Completing the CMS-1500 Claim Form - Field 14 -33




Provider of Service or Supplier Information (Fields 14-33)

Field Number : 14
Field Description : Date of current illness, injury or pregnancy
Data Type : Not required
Instructions : Not applicable.




Field Number : 15
Field Description : If patient has had same or similar illness, give first date
Data Type : Not required
Instructions : Not applicable.




Field Number : 16
Field Description : Dates patient unable to work in current occupation
Data Type : Conditional
Instructions : Required if the patient is eligible for disability or worker's compensation benefits due to this illness. Enter the “From” and “To” dates the patient was unable to work in MMDDYY or MMDDCCYY format.


Field Number : 17
Field Description : Name of referring physician or other source
Data Type : Conditional
Instructions : Enter the name of the referring physician or other source if applicable.




Field Number : 17a
Field Description : ID number of referring physician
Data Type : Conditional
Instructions : The CMS-assigned UPIN of the referring or ordering physician listed in Field 17. Enter only the seven-digit base number and the one-digit check digit.

NOTE: The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.
The other ID number of the referring provider, ordering provider, or other source should be reported in 17a in the shaded area. The qualifier indicating what the number represents should be reported in the qualifier field to the immediate right of 17a. The NUCC defines the following qualifiers, since they are the same as those used in the electronic 837 Professional 4010A1:
• 0B – State license number
• 1B – Blue Shield provider number
• 1C – Medicare provider number
• 1D – Medicaid provider number
• 1G – Provider UPIN number
• 1H – CHAMPUS identification number
• EI – Employer’s identification number
• G2 – Provider commercial number
• LU – Location number
• N5 – Provider plan network identification number
• SY – Social Security number (The Social Security number may not be used for Medicare)
• X5 – State industrial accident provider number
• ZZ – Provider taxonomy




Field Number : 17b
Field Description : NPI
Data Type : Required
Instructions : Enter the NPI of the referring or ordering physician listed in item 17 as soon as it is available. The NPI may be reported as of October 1, 2006.

NOTE: Field 17a and / or 17b is required when a service was ordered or referred by a physician. Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when a service was ordered or referred by a physician.




Field Number : 18
Field Description : Hospitalization dates related to current services
Data Type : Conditional
Instructions : Required if this claim includes charges for services rendered during an inpatient admission. Enter dates in MMDDYY format.


Field Number : 19
Field Description : Reserved for local use
Data Type : Conditional
Instructions : If billing for intensive outpatient programs, please write "IOP" in this space.


Field Number : 20
Field Description : Outside lab/charges
Data Type : Conditional
Instructions : Enter if lab tests performed and billed on this claim were processed by a lab outside the provider’s premises.


Field Number : 21.1-4
Field Description : Diagnosis or nature of illness or injury
Data Type : Required
Instructions : Enter a valid ICD-9 diagnosis code, coding to the highest level of specificity (include fourth and fifth digits if applicable) that describes the principal diagnosis for services rendered.


Enter up to four codes in priority order (primary, secondary, etc.)


Field Number : 22
Field Description : Medicaid resubmission code/original reference number
Data Type : Conditional
Instructions : List the original reference (claim) number for resubmitted claims.


Field Number : 23
Field Description : Prior authorization number
Data Type : Not required
Instructions : Not applicable.


Field Number : 24a
Field Description : Dates of service
Data Type : Required
Instructions : Enter “From” and “To” dates of service in MMDDYY or MMDDCCYY format. Line items can include no more than two dates of service for the same procedure code. When “from” and “to” dates are shown for a series of identical services, enter the number of days or units in column C.


Field Number : 24b
Field Description : Place of service
Data Type : Required
Instructions : Enter the appropriate place of service code.


Field Number : 24c
Field Description : EMG
Data Type : Not required
Instructions : Not applicable.


Field Number : 24d
Field Description : Procedures, services or supplies CPT/HCPCS
Data Type : Required
Instructions : Enter a valid CPT or HCPCS code for each service rendered.


Field Number : 24d
Field Description : Modifier
Data Type : Conditional
Instructions : Enter a valid CPT or HCPCS code modifier for each service entered.**
HIPAA: Billing Code Modifiers
** When submitting a CPT or HCPC code with a modifier, it is critical that the modifier be placed in its appropriate allocation. HIPAA allows up to four (4) modifiers to be used. The order of the modifiers has a particular meaning. The order of the modifiers is found below:

Modifier ONE: This field is dedicated for modifiers that affect or define the service (e.g., TG modifier to identify a ‘complex high level of care’)

Modifier TWO: This field is dedicated for modifiers that identify pricing (e.g., HA modifier to identify ‘child/adolescent’ or HN modifier to identify ‘bachelors level’)

Modifier THREE & FOUR: These fields are dedicated for modifiers that identify statistics (e.g., HV ‘funded by State Addictions Agency’)

If you have any questions regarding the placement of Modifiers, please contact your Regional Provider Relations office for instructions.


Field Number : 24e
Field Description : Diagnosis pointer
Data Type : Conditional
Instructions : Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line. When multiple services are performed, the primary reference number for each service, either a 1, 2, 3 or 4, is shown. Do not enter the ICD-9 diagnosis code.


Field Number : 24f
Field Description : Charges
Data Type : Required
Instructions : Enter the provider’s billed charges for each service.

Field Number :  24g
Field Description : Days or units
Data Type : Required
Instructions : Enter the appropriate number of units or days that correspond to the “From” and “To” dates indicated in Field 24a.

Field Number : 24h
Field Description : EPSDT family plan
Data Type : Conditional
Instructions : If service was rendered as part of or in response to an EPSDT panel, mark an "X" in this block.


Field Number : 24i
Field Description : ID Qual.
Data Type : Conditional
Instructions : If the provider does not have an NPI, enter the appropriate qualifier and identifying number in the shaded area. There will always be providers who do not have an NPI and will need to report non-NPI identifiers on their claim forms. The qualifiers will indicate the non-NPI number being reported.



Field Number : 24j
Field Description : Rendering Provider ID.#
Data Type : Required
Instructions : Enter the NPI number in the un-shaded area of the field.


Field Number : 25
Field Description : Federal Tax ID number and type:
• Social Security Number or
• Employer Identification Number
Data Type : Required
Instructions : Enter the nine-digit Employee Identification Number (EIN) or Social Security Number under which payment for services is to be made for reporting earnings to the IRS. Enter an "X" in the appropriate box that identifies the type of ID number used for services rendered.


Field Number : 26
Field Description : Patient's account number
Data Type : Optional
Instructions : Enter the unique number assigned by the provider for the patient. If entered, the patient account number will be returned to the provider on the Provider Summary Voucher.


Field Number : 27
Field Description : Accept assignment?
Data Type : Required
Instructions : Enter an "X" in the appropriate box.


Field Number : 28
Field Description : Total charge
Data Type : Required
Instructions : Enter the total charge for this claim. This is the total of all charges for each service noted in Field 24f.


Field Number : 29
Field Description : Amount paid
Data Type : Conditional
Instructions : Enter the total amount paid by the patient for services billed on this claim.


Field Number : 30
Field Description : Balance due
Data Type : Conditional
Instructions : Enter the total balance due for the services less any amount entered in Field 29.


Field Number : 31
Field Description :  Signature of physician or supplier including degrees or credentials
Data Type : Required
Instructions : Signature of physician or supplier including degree(s) or credentials and date of signature. NOTE: The person rendering care must sign and indicate licensure level.


Field Number : 32
Field Description : Name and address of facility where services were rendered
Data Type : Required
Instructions : Enter name and address where services are rendered.


Field Number :32a
Field Description : a.
Data Type : Required
Instructions : Enter the NPI of the service facility

Field Number : 32b
Field Description : b.
Data Type : Not Required
Instructions : Not Applicable

Field Number : 33
Field Description : Physician’s/supplier's billing: name, address, zip code and phone number
Data Type : Required
Instructions : Enter the appropriate billing information.


Field Number : 33a
Field Description : PIN number
Data Type : Required
Instructions : Enter the NPI of the billing provider or group.


Field Number : 33b
Field Description : Group number
Data Type : Not Required
Instructions : Not Applicable after May 23, 2007

CMS-1500 KIDNEY DISEASE PROGRAM BILLING INSTRUCTIONS




INTRODUCTION

These billing instructions have been prepared to provide proper procedures and instructions for
the Kidney Disease Program providers who use the CMS-1500 (08-05) form.

BILLING INFORMATION

Providers must bill on the CMS-1500 claim form. Claims can be submitted in any quantity and
at any time within the filing limitation.

Filing Statutes: Claims must be received within 6 months of the date of service. The following
statutes are in addition to the initial claim submission.

• 3 months from the date of any intermediary payment, i.e., Medicare, other third party insurance (Must include copy of EOB.)

PROCEDURES FOR SUBMITTING HARDCOPY MEDICARE CLAIMS

Billing a CMS-1500 with a Medicare EOMB:

On the Medicare EOMB, each individual claim is generally designated by two horizontal lines. Therefore, you should complete one CMS-1500 form per set of horizontal lines.
• When billing Medical Assistance, the information on the CMS-1500 must be identical to the information that is between the two horizontal lines on the Medicare EOMB.
o Dates of service must match
o Procedure codes must match
o Amount(s) on line #24F of the CMS-1500 must match the “amount billed” on the EOMB.

• Each CMS-1500 claim must be totaled with accompanying EOB attached.

• When submitting your Medicare claims for payment, the writing should be legible. In addition, when attaching a copy of the Medicare EOMB make sure it is clear and that the entire EOMB, including the information on the top and the glossary is included on the copy. In order for KDP to pay for co-insurance and deductibles, the CMS-1500 and the Medicare EOMB must be submitted.

Claims should be sent to the original claims address:
Kidney Disease Program
201 W. Preston Street, SS3
Baltimore, MD 21203

The Program will not accept computer-generated reports from the provider’s office as proof of timely filing. The only documentation that will be accepted is a remittance advice, Medicare/Third-party EOB, and/or a returned date stamped claim from the Program.

All claims should be mailed to the following address:

Department of Health and Mental Hygiene
Kidney Disease Program
201 W. Preston Street, Room SS3
Baltimore, MD 21201

Thursday, May 27, 2010

Single carrier TPR codes

UD Service under deductible
NC Service not covered by insurance policy
PN Patient not covered by insurance policy
IC Insurance coverage canceled/terminated
IL Insurance lapsed or not in effect on date of service
IP Insurance payment went to policyholder
PP Insurance payment went to patient
NA Service not authorized or prior authorized by insurance
NE Service not considered emergency by insurance
NP Service not provided by primary care provider/facility
MB Maximum benefits used for diagnosis/condition
RI Requested information not received by insurance from patient
RP Requested information not received by insurance from policyholder
MV Motor Vehicle Accident Fund (MVAF) maximum benefits exhausted
AP Insurance mandated under administrative/court order through an absent parent and not paid within 30 days
OT Other (if above codes do not apply, include detailed explanation of why there was no payment from insurance)

Multiple carrier TPR codes




MP Primary insurance paid – secondary paid
SU Primary insurance paid – secondary under deductible
MU Primary and secondary under deductible
PU Primary insurance under deductible – secondary paid
SS Primary insurance paid – secondary service not covered
SC Primary insurance paid – secondary patient not covered
ST Primary insurance paid – secondary canceled/terminated
SL Primary insurance paid – secondary lapsed or not in effect
SP Primary insurance paid – secondary payment went to patient
SH Primary insurance paid – secondary payment went to policyholder
SA Primary insurance paid – secondary denied – service not authorized
SE Primary insurance paid – secondary denied – service not considered emergency
SF Primary insurance paid – secondary denied – service not provided by primary care provider/facility
SM Primary insurance paid – secondary denied – maximum benefits used for diagnosis/condition
SI Primary insurance paid – secondary denied – requested information not received from policyholder
SR Primary insurance paid – secondary denied – requested information not received from patient
MC Service not covered by primary or secondary insurance
MO Other (if above codes do not apply, include detailed explanation of why there was no payment from insurances)

How to prepare CMS 1500 paper claim.

PREPARING THE CMS-1500 CLAIM FORM

The Form CMS-1500 (Health Insurance Claim Form) is the standard claim form used by a non-institutional provider or supplier to bill Medicare contractors and durable medical equipment contractors when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The National Uniform Claim Committee (NUCC) is responsible for the maintenance of the form CMS-1500. CMS and contractors do not provide the form to providers for claim submission. Forms may be purchased from the U.S. Government Printing Office at (866) 512-1800, local printing companies in your area and/or office supply stores. Each of these sources sells the Health Insurance Claim Form CMS-1500 in various configurations (single part, multi-part, continuous feed, laser, etc.)

NUCC revised the Form CMS-1500. The new version, Form CMS-1500 (08-05) replaced the CMS-1500 (12- 90) version. The 08-05 version of the CMS-1500 form was effective June 29, 2007. Medicare will reject any 12-90 version forms received.


Intelligent Character Recognition (ICR)
NHIC is using an Intelligent Character Recognition (ICR) system to capture claims information directly from the CMS-1500 claim form.

ICR benefits include:
�� Greater efficiency;
�� Improved accuracy;
�� More control over the data input, and
�� Reduced data entry cost for the Medicare program.


The ICR is capable of going beyond simply scanning claims data into the computer and has a sophisticated computer “brain” which verifies claims information against several data files as well as performing various claims processing functions.

With the ICR system, it is important that claims be submitted with proper and legible coding. This is because the ICR output is largely dependent on the accuracy and legibility of the claim form submitted.


If you are not billing electronically, consider it! However, when you bill on paper, follow these tips when completing your CMS-1500 forms:

The font should be:
  •  Legible (Change typewriter ribbon/PC printer cartridge frequently, if necessary. Laser printers are recommended)
  •  In Black Ink
  • Pica, Arial 10, 11 or 12 font type
  • CAPITAL letters
The font must NOT have:
  •  Broken characters
  • Script, Italics or Stylized font
  •  Red ink
  •  Mini-font
  •  Dot Matrix font
Do NOT bill with:

  •  Liquid correction fluid changes.
  • Data touching box edges or running outside of numbered boxes (left justify information in each box).
Exception: when using the 8-digit date format, information may be typed over the dotted lines shown in date fields, i.e., Item 24a.
  •  More than six service lines per claim (use a new form for additional services);
  •  Narrative descriptions of procedure, narrative description of modifier or narrative description of diagnosis (the CPT, Modifier or ICD-9-CM codes are sufficient);
  •  Stickers or rubber stamps (such as “tracer,” “corrected billing,” provider name and address,
  • NHIC’s address at top of the form;
  •  Special characters (i.e., hyphens, periods, parentheses, dollar signs and ditto marks).
  •  Handwritten descriptions;
  •  Attachments smaller than 8 1/2 x 11.

The claim form must be:

  •  An original CMS-1500 printed in red “drop out “ ink with the printed information on back (photocopies are not acceptable);
  •  Size - 8½” x 11” with the printer pin-feed edges removed at the perforations;
  •  Free from crumples, tears, or excessive creases (to avoid this, submit claims in an envelope that is full letter size or larger);
  •  Thick enough (20-22 lbs.) to keep information on the back from showing through;
  •  Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out information or white out.
NOTE: The following examples are in black and white. An original CMS-1500 claim form is printed in red “drop out” ink with the printed information on the back.

Wednesday, May 26, 2010

CMS 1500 Fiels 1 - 10 - Instruction to file the claim

Top section of the CMS 1500 form

Box 1a - Required

Recipient ID Number
�� Enter the client’s eight-character prime identification number.
�� Enter the number exactly as it appears on the Medical Care Identification.


Box 2 - Required

Patient’s Name
�� Enter the client’s name exactly as it is printed on the Medical Care Identification.
�� Use the client’s last name first.
�� Do not use nicknames.


Box 9 - Optional

Third Party Resource
�� If the client has other medical coverage, enter the appropriate two-digit third party resource (TPR) explanation code.
�� A code must be listed when the other insurance did not make a payment.
�� A code is always required when the client has more than one other insurance carrier.
�� TPR codes can be found in your specific provider supplemental information.

Box 10 - Optional

Patient’s Condition
�� Check the appropriate box only when an injury is involved.

�� Do not check any boxes if there is no injury to report.

Box 17 - 23 - How to file the claim - CMS 1500

Middle section of CMS 1500 form


Box 17a - Optional

Referring Provider Number

�� Enter the six (6)-or nine (9)-digit DHS provider number of the referring provider.
�� Beginning 12/09/2008, newly enrolled providers will have a 9-digit provider number.
�� This may be required if the client has a Primary Care Manager (PCM) or the service requires a referral (e.g., Physical Therapy, Occupational Therapy or Speech Therapy).


Box 17b - Optional

Referral National Provider Identifier (NPI)

�� If information was entered in box 17a (Primary Care Manager, or other referral) the corresponding NPI is entered here.
�� Enter the ten-digit NPI of the referring provider.


Box 21 - Required

Diagnosis Code
�� Enter the client’s diagnosis/condition.
�� The diagnosis code must be the reason chiefly responsible for the service being provided as
shown in medical records.
�� You may enter up to four codes and they must be carried out to its highest degree of specificity.
�� Do not use the decimal point.

Note: Diagnosis codes are not required for transportation providers.


Box 23 - Optional

Prior Authorization Number
�� If the service you provided requires prior authorization (PA), enter the ten-digit prior authorization number that was issued for the service.
�� Only use one prior authorization number per claim form.
�� Do not bill prior authorized and non-authorized services on the same claim form.

Box 24 - 33 - How to billing - CMS 1500

Bottom section of the CMS 1500 form


Supplemental information

Shaded line

�� In the shaded area across Fields 24A through 24H, enter supplemental information about the service rendered.
�� If entering more than one item of information on a line, make sure each item begins with a qualifier and is separated by at least 1 blank space.


Box 24A - Required

Date of Service
�� This box must list numeric dates of service.
�� If billing for one day, complete only the “from” column.
�� If the “from and to” dates are used, a service must be on consecutive days and provided no more than once per day.

Box 24B - Required

Place of Service
�� Enter the two-digit place of service code of where the service was provided.
�� Place of service codes can be found in CPT/HCPCS codebooks or on the Web site at:
http://www.medicarepaymentandreimbursement.com/2010/05/full-place-of-service-codes.html


Box 24C - Optional

Emergency Indicator
�� If the service you provided was a result of an emergency, enter a “Y” for “yes” in this box for each line item.
�� If this was not an emergent service, leave blank or enter a “N” for “nonemergent”.


Box 24D - Required

Procedure Code
�� Enter the five-digit/character CPT or HCPCS code(s) for the specific service provided.
�� Optional - Enter up to four two-digit national modifiers that relate to this service.
�� For procedure codes that indicate “unlisted,” you must attach an operative/medical report.


Box 24E - Required

Diagnosis Pointer
�� Enter the one-digit diagnosis code reference number (pointer) as shown in box 21 to relate
the date of service and the procedure performed to the primary diagnosis.
�� Do not enter the actual ICD-9-CM code here.


Box 24F - Required


Total Charges
�� Enter the total usual and customary charge for each line.
�� Do not list credits.
�� Do not use dashes.


Box 24G - Required

Service Days or Units
�� Enter the number of days or units for each number of consecutive days or services as
indicated in box 24A.
�� Some services are billed by units depending on the service provided.


Box 24J - Optional

Rendering Provider ID
�� This box is only required when clinics or group practices use a specific billing provider number in box 33. This identifies who rendered the service.
�� Shaded - Enter the six (6)-or nine (9)- digit DHS provider number of the individual rendering the service.
�� Non-shaded - Enter the ten-digit NPI of the rendering provider that was identified in the shaded area.


Box 26 - Optional

Patient Account Number
�� Enter your patient account number here.
�� This box allows up to twelve characters.
�� This number will appear on your Remittance Advice (RA).


Box 28 - Required

Total Charge
�� Enter the total charge amount for all services listed in column 24F.
�� Each claim form is a separate document, and is to be totaled as such.


Box 29 - Optional

Amount Paid
�� Enter the total amount paid by any prior resource(s).
�� Do not include write-offs.

�� Do not include copayments.


Box 30 - Required

Balance Due
�� Enter the balance due.
�� Box 28 minus box 29 must equal box 30.


Box 33 - Required

Billing Provider Information
�� Box 33 - (Billing provider info & phone number) Enter the name and address of the provider that is requesting to be paid for the services rendered.
�� 33a - (NPI) Enter the ten-digit NPI of the billing provider.
�� 33b - (Other ID) Enter the six (6)-or nine (9)-digit provider number of the billing provider.
Note: Non-medical services do not require NPI (e.g., taxis).

Where to enter NDC number and anesthsia service in CMS 1500

Supplemental Information

* More than one supplemental item can be reported.
* Enter the first qualifier and number/code/information.
* After the first item, enter three blank spaces and then the next qualifier and number/code /information.
* The following three slides are examples of different types of supplemental information.

How to enter supplemental information on BOX 24

Supplemental Information

Box 24A - 24H

�� DMAP accepts the following types of supplemental information that can be entered in the shaded line across box 24A through box 24H:

• Anesthesia duration in hours and/or minutes with start and end times
• Narrative description of unspecified codes
• National Drug Codes for drugs
• Vendor Product Number
• Health Care Uniform Code, formerly Universal Product Code
• Contract rate

�� The following qualifiers are to be used when reporting these services:

Qualifier                     Description
7                                 Anesthesia
ZZ                              Narrative description of unspecified codes
VP                              Vendor Product Number
OZ                             Health Care Uniform Code
CTR                          Contract rate
N4                             National Drug Code, also use the following:
F2                              International unit
GR                             Gram
ML                            Milliliter
UN                            Unit

SAMPLE CMS - 1500 form

Click the image for see full size sample CMS 1500 claim form.

CMS 1500 - Definitions

What is CMS 1500 ?

Definition :
The HHS agency responsible for Medicare and parts of Medicaid.? Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Definition  HCFA

HCFA: The Health Care Finance Administration, the part of the U.S. Department of Health and Human Services (HHS) that is responsible for administering Medicare and Medicaid.

 CMS-1450 - The uniform institutional claim form.

CMS-1500   - The uniform professional claim form.

Completed CMS 1500 form




Secondary claim submission

General Insurance Information - Billing Your Secondary Insurance Company

Secondary Insurance Billing

Secondary billing is a necessary component to any healthcare organization; yet in order to receive every secondary dollar owed, many organizations are forced to invest valuable time and resources that can cost far more than the benefit of the secondary dollars themselves. Unless the secondary payer supports automatic crossover claims, secondary billing is still performed using a mostly manual, paper-based process. In almost every case processing secondary claims can be frustrating and time consuming, and devoting staff time to process claims that are often times in much smaller dollar amounts, can make the payoff seem not worth the effort required.

Billing your secondary insurance company can be a daunting task if you are not fully aware of the process. The information provided below is critical in helping you through this process so it doesn't feel so overwhelming. Understanding the terms used by insurance companies, determining if a policy is primary or secondary and the billing process will help to make this more manageable.

Insurance Company Terms

Insurance companies use terms such as primary, secondary, explanation of benefits (EOB) and claims. Primary insurance means this is the insurance policy that will be used first when you receive medical services. Sometimes the policy is primary because it’s your only policy and in a situation when you have two policies, the insurance companies make this determination. The explanation of benefits form can be used when there are two policies and you need to send a copy of this form (EOB) to your secondary provider. This form explains what the benefits are of that insurance plan. An insurance claim refers to the bill sent to the insurance company for the services you received.

Billing Your Secondary Insurance Company

General Insurance Information - Billing Your Secondary Insurance Company

Determining Primary or Secondary

When you have two insurance companies that provide coverage for you, it is important they know about each other. Initially when you receive coverage from a second insurance, be sure to call both insurance companies and inform them of the other policy. During this phone call, it’s important to provide them with the name of t he insurance company, your ID number, and who the subscriber is on the policy. At this time they will be able to determine which coverage will be primary or secondary. The insurance companies have their own method of determining this and many people are under the misunderstanding that the primary insurance is the policy you had first.  This is not the case. If you do not notify each company of the other policy it may result in consequences when it comes time to bill and you may end up owing more money than you would if they were properly notified.

Billing Process

The first step in this process is to submit the claims to your primary insurance company. In some cases the provider would submit the claims and in other situations you would submit your claims. Once the payment is received from the primary insurance, you will need to send the claim with the explanation of benefits form to your secondary insurance company. At this point the secondary will review the balance unpaid by the primary in order to determine what they are required to pay.

Keeping a Record

If you have any questions regarding your insurance policies you can call your insurance company at the number listed on the back of your card. As a result of insurance companies being so large, with so many customer service representatives, be sure to write down the name of the person you spoke with along with the time and date you called. Keeping a record of your contact with them will help to decrease your confusion if you were to speak to several different people.

 

CMS 1500 - points to remember

Claim form billing instructions - CMS 1500


Overview


This step-by-step presentation is intended to provide information to assist those who bill the Division of Medical Assistance Programs (DMAP) for Medicaid services complete the 08/05 CMS 1500 billing form correctly the first time. If applicable, this presentation is to be used in conjunction with General Rules, provider guidelines and supplemental information.

Before you bill

�� Read your provider guidelines.
�� Verify client eligibility on the date of service.
�� Make sure you bill all prior resources first.
�� Use commercially available “red form” versions of the CMS 1500.

A few tips!

�� When submitting handwritten claim forms, you must use blue or black ink; never use red ink.
�� Make sure your handwriting is legible.
�� If possible, submit no more than six lines of services per claim form.
�� Do not use liquid whiteout.
�� Check your printer alignment.



Services billed on the CMS 1500
�� Durable Medical Equipment Services
�� School Based Medical Services
�� Professional Services
• Contract RN
• Licensed professionals

�� Non-Medical Professional
• Secured Transportation
• Copy Services
• Miscellaneous Medical Services
• Sex Offender Polygrapher
• Wheelchair Coach/Services
• Taxi

�� Medical Professional Providers
• Air/Ground Ambulance
• Ambulatory Surgical Center
• Billing Provider
• Billing Service/Agent
• Chemical Dependency
• Chiropractor
• Family Planning Clinic
• Free Standing Birthing Center
• Hearing Aid Provider
• Independent Lab
• Licensed Midwife
• Naturopath
• Mental Health
• Nurse Anesthetist
• Nurse Practitioner
• Occupational Therapist
• Optometrist
• Physical Therapist
• Physician
• Podiatrist
• Portable X-Ray
• Psychologist
• Public Clinic
• Registered Nurse
• Rural Health Center
• Federally Qualified Health Center
• Dispensing Optician
• Indian Health
• Lifeline
• Targeted Case Management
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