Wednesday, June 30, 2010

How to submit CMS 1500 claim form - Healthnet

Claims Submission Information Instructions -- Healthnet for Non-participating Providers

When submitting claims, providers must include, at a minimum, all of the following required information:
•    Member's (subscriber's) ID number
•    Patient's name and date of birth
•    Employer group number
•    Submitting provider's tax ID number or Social Security number
•    State license number of attending provider
•    Submitting provider's name and address
•    ICD-9 diagnosis code
•    Date(s) of service Billed charges
•    Current year CPT or HCPCS procedure code (physician) with all applicable modifiers LML or UB-92 revenue code with narrative description (hospital)
•    CMS place of service code (professional claims only)
•    UB bill type
•    Number of days or units for each service line (professional claims only)
•    Authorization number and all applicable information, when authorization is required
•    UPIN number for professional claims
•    Medicare number for institutional claims when applicable



To avoid possible denial or delay in processing, the above information must be correct and complete.

The following providers must include additional information as outlined:

•    Emergency services providers: The claim must include a legible emergency department report and any state-designated data requirements included in statutes or regulations

•    Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations

•    On-call physicians: Where applicable, physicians who are on call for a primary care physician (PCP) do not require a referral. The name of the PCP should be noted on the claim in Box 19 or 23 on the CMS-1500 claim form. For self-referrals the provider should indicate Self-Referred in Box 17 of the CMS-1500

•    Providers not specified: A properly completed paper or electronic billing instrument submitted in accordance with Health Net's specifications and any state-designated data requirements included in statutes or regulations
General Billing Requirements:
•    ID number: Enter the corresponding identification (ID) number as noted:
o    Member ID number (Medi-Cal): The nine-character ID found on patient's Health Net ID card
o    Subscriber ID number (HMO, POS, PPO, EPO, Flex Net,AIM, and Healthy Families Program): The nine-character ID (the letter "R" followed by eight digits) found on patient's Health Net ID card
•    Employer group number: The number assigned to the subscriber's employer group located on the member's ID card.
•    UPIN or state license number:Six-digit universal provider identification number (UPIN) or state license number of all attending providers.
o    When billing for more then one attending provider, indicate the UPIN on the appropriate detail line
o    For physicians, the state license number should be entered as a seven-digit number "A0nnnnn." When "a" is the alpha character shown on the state license (A, C, G), "0" is the filler zero and "nnnnn" are the five numeric characters in the state license number
o    All other providers use their state-assigned license number without modifications

Friday, June 25, 2010

CMS 1500 - BOX 32: SERVICE FACILITILY LOCATION INFORMATION

If services were in a location other than the Provider’s office or the member’s home, enter the name and address of that facility.

32 a. Enter the Facility NPI number. Not required at this time.

32 b. Enter the 2-digit MaineCare Identifier (1D) and one space followed by the Facility Provider number. Do not  enter the Servicing Provider ID number here. Not required at this time.


Item 32 Form CMS-1500 (12-90) - Enter the name and address, and ZIP Code of the facility if the services were furnished in a hospital, clinic, laboratory, or facility other than the patient's home or physician's office. Effective for claims received on or after April 1, 2004, enter the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only one name, address and ZIP Code may be entered in the block.

 If additional entries are needed, separate claim forms shall be submitted. Providers of service (namely physicians) shall identify the supplier's name, address, ZIP Code and PIN when billing for purchased diagnostic tests. When more than one supplier is used, a separate Form CMS-1500 shall be used to bill for each supplier. For foreign claims, only the enrollee can file for Part B benefits rendered outside of the United States.

These claims will not include a valid ZIP Code. When a claim is received for these services on a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should be determined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for disposition of the claim. The carrier processing the foreign claim will have to make necessary accommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIP Code. For durable medical, orthotic, and prosthetic claims, the name, address, or PIN of the location where the order was accepted must be entered (DMERC only). This field is required. When more than one supplier is used, a separate Form CMS-1500 shall be used to bill for each supplier. This item is completed whether the supplier's personnel performs the work at the physician's office or at another location.

If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area (HPSA) or Physician Scarcity Area (PSA), the physical location where the service was rendered shall be entered if other than home. If the supplier is a certified mammography screening center, enter the 6-digit FDA approved certification number. Complete this item for all laboratory work performed outside a physician's office. If an independent laboratory is billing, enter the place where the test was performed, and the PIN.

BOX 29: AMOUNT PAID - secondary claim field

Attach the third party Explanation of Benefits (EOB)
for all claims involving a third party when balance billing
secondary after you have received payment or denial from
the primary health plan

If payment was made, you must enter the amount
of the insurance payment in Box 29, as well as attach
the third party Explanation of Benefits (EOB).

In order for the claims payment system to properly
distribute third party payments, only those line items
paid by the third party can be billed on the same claim
form.

Those charges that have been denied by the insurer,
where no third party payment was made, must be
billed on a separate claim form, and you must include
the third party Explanation of Benefits (EOB).

Do not enter the Medicare payment in Box 29 if you
are billing for Medicare coinsurance or deductible

TIP:
Do not enter the member’s anticipated copay amount. It will be
automatically deducted in the claims process.

Box 24F: Charges must equal the allowed amount that you and the
insurance company agreed to, as shown on insurance company’s
Explanation of Benefits (EOB).

Box 28: Enter the total charges. This must equal the total of the
individual line item charges in 24F.

Box 29: Enter the amount paid by insurance company/third party. The
third party amount must equal the actual third party payment, plus any
withheld amount shown on the insurance company’s Explanation of
Benefits. You must enter this amount on the claim form, and you must
attach the Explanation of Benefits.

Box 30: Enter balance due. This can not exceed the member
responsibility shown on the Explanation of Benefits

cms 1500 BOX 24 A - 24J- how to fill.

For each line item billed, you must include one date, one place of service, one procedure code, and one amount charged per line. For a paper claim, you may not bill more than six lines.


BOX 24A: DATE(S) OF SERVICE

Enter both “From” and “To” dates of service using either six-digit (MMDDYY) or eight-digit (MMDDYYYY) format. Do not use commas, dashes, or slashes in the date.

Dates must be consecutive and continuous. If the service was provided on only one day, just put that date in the From field. On each line, the From and To dates must be during one month. Use the next line for the next month.


BOX 24B: PLACE OF SERVICE
Enter a two-digit Place of Service code


BOX 24C: EMG

Enter a Y to prevent copay from being deducted if you are not billing services that are exempt from copay

BOX 24D: PROCEDURES, SERVICES OR SUPPLIES

Enter the appropriate procedure code and modifier(s), if necessary in the unshaded area..

NOTE: The shaded area at the top of this box is to be used for supplemental information
only



BOX 24E: DIAGNOSIS POINTER

From Box 21, enter the line number or numbers (1, 2, 3, and/or 4) that list the diagnosis codes. Do not enter the codes themselves. List only the line numbers.

BOX 24F: $ CHARGES

Enter the usual charge for the service you provided based on the policy section under which you are billing.

BOX 24G: DAYS OR UNITS

Enter the number of days of service or the units of supplies provided. Do not use decimal points or fractions. Round off to the nearest whole number. Enter 1 only if 1 unit was provided. (For example: For Indian Health Centers or Rural Health Centers, 1 unit of a visit is 1, not the units of itemized
services provided in that visit.)

24I: ID QUALIFIER

You must enter the appropriate qualifier in the shaded area of this box 1D indicates MaineCare Servicing Provider Number should be in Box J.


24J: RENDERING PROVIDER ID NUMBER

Enter the Servicing Provider ID number in the shaded area, if applicable. Enter the Servicing Provider NPI number in the area that is  not shaded. MaineCare does not require an NPI at this time.
If a Servicing Provider ID number is not required, leave this field empty.

CMS1500 - BOX 19: RESERVED FOR LOCAL USE

If you are billing a J code in Box 24D, enter the National
Drug Code (NDC) for that drug. Do not enter the description
of the drug, and do not enter NDC before the actual NDC
code. Only one J code may be billed per claim.

NDCs printed on packages often have fewer then 11 digits,
with hyphens (-) separating the number into three segments.
For a complete 11-digit number, the first segment must have 5
digits, the second segment must have 4 digits, and the third
segment must have 2 digits. Leading zeros are added leftjustified,
wherever they are needed to complete a segment with
the correct number of digits.

Package Number                 Zero Fill (5-4-2)                             11-digit NDC
1234-1234-12                     (01234-1234-12)                        01234123412
12345-123-12                      (12345-0123-12)                        12345012312

CMS 1500 - BOX 11: INSURED’S POLICY GROUP OR FECA NUMBER

If the member has a secondary insurance these boxes must be completed.

BOX 11a: INSURED’S DATE OF BIRTH AND SEX

If YES is checked in Box 11d, enter the month, day and year
the policyholder was born. The format for a birth date must be
MMDDYYYY.

Enter an X in the appropriate box for the policyholder’s sex.
BOX 11b: EMPLOYER’S NAME OR SCHOOL NAME
If YES is checked in Box 11d, enter the name of the policyholder’s
employer or school.

BOX 11c: INSURANCE PLAN NAME OR PROGRAM NAME

If YES is checked in Box 11d, enter the name of the policyholder’s
insurance plan or program. Do not enter Medicare or the name of
any State program.

BOX 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?


If the member is covered by other primary insurance
and he/she is not the policyholder, enter an X in the YES box
and also complete Fields 9a–9c. If there is no other insurance, enter an X in the NO box.

Thursday, June 24, 2010

Who Must Use the CMS/HCFA 1500

If you are one of the following providers, you must use the CMS/HCFA 1500
form:
Advance Practice Registered Nursing Services
Ambulances
Ambulatory Care Clinics
Ambulatory Surgical Centers
Audiologists
Chiropractic Services
Community Support Services
Consumer Directed Attendant Services
Day Habilitation Services for Persons with Mental Retardation
Day Health Services
Day Treatment Services
Developmental and Behavioral Clinics
Medical Supplies and Durable Medical Equipment
Early Intervention Services
Family Planning Clinics
Federally Qualified Health Centers
Genetic Testing and Clinical Genetic Services
Hearing Aids and Services
Home and Community Based Benefits for the Elderly and
for Adults with Disabilities
Home and Community Based Benefits for Members
with Mental Retardation
Home and Community Based Benefits for the Physically Disabled
Home Based Mental Health Services
Independent Laboratories
Licensed Clinical Social Workers, Licensed Clinical Professional
Counselors, and Licensed Marriage and Family Therapist Services
Medical Imaging Services
Occupational Therapy Services
Optometrists
Outpatient Mental Health Providers
Physical Therapy Services
Physician Services
Psychological Services
Podiatrist Services
Rehabilitation Services
Rural Health Clinic Services
School Based Rehabilitation Services
Speech and Hearing Services
Substance Abuse Treatment Services
Targeted Case Management Providers
Transportation/Wheelchair Van Services
VD Clinics
Vision Services

What is ID qualifier in CMS 1500 - 0B, 1B, 1C, 1D, ZZ ON UB 04

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 – A list of the valid Taxonomy codes


Claim Filing Indicator Code

The Claim Filing Indicator Code identifies the type of claim being filed. BCBSNC requires that the first instance of this code (2000B, SBR09) within the 2000B looping structure be either a value of BL (Blue Cross/Blue Shield) or ZZ (Mutually Defined – for subscribers covered under the State Employee Health Plan).

P015 For the first instance of SBR09 within this Hierarchical Level (HL), use a value of BL (Blue Cross/Blue Shield) , except for subscribers covered by State Health Employee Plan, use a value of “ZZ” (Mutually Defined)

BCBSNC Business Edits for the 837 Health Care Claim

The following proprietary error codes and messages are returned via the Claims Audit Report. The Claims Audit Report can be accessed from your electronic mailbox for direct submitters, or online, via Blue e (https://providers.bcbsnc.com/providers/login.faces ) - see the 837 Claim Denial Listing.

Important Note: These error codes are not returned for Medicare Advantage or Medicare Supplemental claims. Error Code* Explanation Message 837 Professional Cross-references4

P004 When Other Insured's Entity Code (NM101) = IL, Entity Qualifier must equal '1'. 2330A, Other Subscriber Name, NM102

P005 Newborn charges should not be filed on the Parent's claim. They should be filed separately under the baby's name and Member ID. 2400, Professional Service, SV101:2

P006 Member ID must be valid. 2010BA, Subscriber Name, NM109

P015 The first occurrence of Claim Filing Indicator must be BL or ZZ. 2000B, Subscriber Information, SBR09

P018 Member ID not valid for Date of Service (DOS). 2010BA, Patient Name, NM109

P022 Provider NPI not registered with BCBSNC. Please contact Network Management at 1-800-777-1643 to resolve this matter. 2010AA, Provider ID, NM109

P026 Billing Provider Secondary ID Qualifier must equal G2 and/or Billing Provider Secondary ID must be valid for Medicaid submitted claims. 2010BB, Provider ID, REF02

P027 Medicare Advantage/Medicare Supplement Member ID is invalid. Please correct and resubmit. 2010BA, Member ID, NM109

P028 Negative Service Line Paid Amount invalid. 2430, Service Line Paid Amount, SVD02


HCFA 1500 (08-05) Professional Claim Form (for enumerated providers)

HCFA 1500 Data Element HCFA 1500 Field/Box
Billing Provider NPI Field 33a
Billing Provider TIN Field 25
Billing Health Care Provider Taxonomy Field 33b (Qualifier ZZ)
Referring/Supervising Physician NPI Field 17b
Rendering Physician NPI Field 24j

Important: Make sure that your claim software supports the 08-05 version of the 1500 claim form. Reference the 1500 Instruction Manual at Nucc.org for specific details on completing this form.


UB-04 Paper Institutional Claim Form (for enumerated providers)

UB04 Data Element UB04 Field Locator
Billing Provider NPI Form Locator 56
Billing Provider TIN Form Locator 05
Billing Health Care Provider Taxonomy Form Locator 81 (Qualifier B3)
Attending Provider NPI Form Locator 76
Operating Physician NPI Form Locator 77
Other Provider NPI Form Locator 78-79 (With Qualifier: DN Referring, ZZ Other Operating Physician, 82 Rendering and NPI)

See definitions in the UB-04 Data Specifications Manual available at Nubc.org. Any changes to our NPI policy will be preceded with communications to physicians and other health care professionals, organizations and trading partners. Such communications will announce when we will no longer accept HIPAA transactions which do not contain a valid NPI.



ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER SOURCE

Enter the qualifier in the first shaded box of 17a indicating what the number reported in the second shaded box of 17a represents. Atypical providers should report the IHCP LPI provider number in the second box of 17a. Health care providers should report the taxonomy code in the second box of 17a. The qualifier is required when entering the IHCP LPI provider number or taxonomy. Qualifiers to report to IHCP.

1D and G2 are the qualifiers that apply to the IHCP provider number, also called the LPI for the atypical non-health care providers. The LPI includes nine numeric characters and one alpha character for the service location.

ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations. Required when applicable and for any waiver-related services. (Required if applicable.)

RENDERING ID QUALIFIER  Enter the qualifier indicating what the number reported in the shaded area of 24J represents – 1D or G2 for IHCP LPI rendering provider number, or ZZ or PXC for rendering provider taxonomy codes. (Required, if applicable.)

1D and G2 are the qualifiers that apply to the IHCP provider number (LPI) for atypical non-health care providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs.

ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match.


RENDERING PROVIDER ID Enter the LPI if entering the 1D or G2 qualifier in 24I or the taxonomy if entering the ZZ or PXC qualifier in 24I for the rendering provider 1D or G2. (Required, if applicable.) LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s number must be entered here. Taxonomy – Enter the taxonomy code of the rendering provider. (Optional unless required for a one-to-one match.)


BILLING PROVIDERQUALIFIER AND ID NUMBER

Health care providers may enter a billing provider qualifier of ZZ or PXC and taxonomy code. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.

If the billing provider is an atypical provider, enter the qualifier 1D or G2 and the LPI. (Required)


CMS 1500 - Federal Tax id - box 25

Federal Tax ID number and type:
• Social Security
Number or
•Employer
Identification

Number
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

CMS 1500 box 10 A - C

Field Name -

Is the patient’s
condition related to:
•Employment?
•Auto accident?
• Other accident?

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.

10d Reserved for local use Not required Please leave blank.

Sample authorization form

SAMPLE WORDING FOR AUTHORIZATIONS

ONE-TIME AUTHORIZATION

For Use by Provider

Beneficiary Name____________________________HIC#___________________________
I request that payment of authorized Medicare benefits be made to me or on my behalf to (Provider Name) for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
___________________________________________Date_________________
(Beneficiary signature)





For Use by a Facility

Beneficiary Name_______________________________________HIC#________________
I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished me by or in (Name of Facility), including provider services. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or benefits for related services.
____________________________________________Date________________
(Beneficiary signature)



                                                    MEDIGAP AUTHORIZATION



Beneficiary Name________________________________________HIC#_______________
Medigap Policy Number_______________________________________
I request that payment of authorized Medigap benefits be made to either me or on my behalf to (Provider Name), for any services furnished to me by this provider. I authorize any holder of medical information to release to (Name of Medigap Insurer) any information needed to determine these benefits or the benefits payable for related services.
_____________________________________________Date_______________
(Beneficiary signature)

Accept assignment - Field 27 of cms 1500

Item 27

Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment
authorization is given in item 13, the provider of service or supplier shall also be a Medicare
participating provider of service or supplier and must accept assignment of Medicare
benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on
assignment basis:

• Clinical diagnostic laboratory services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives,
certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals and
• Simplified billing roster for influenza virus vaccine and pneumococcal vaccine

Who is Referring physician and ordering physician Box 17

Item 17

Enter the name of the referring or ordering physician if the service or item was ordered or  referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. When a claim involves multiple referring and/or ordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring service.

Referring physician is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Ordering physician is a physician or, when appropriate, a non-physician practitioner, who orders non-physician services for the patient. See Pub. 100-02, Chapter 15 for non-physician practitioner rules. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

Ordering/Referring Terms

Medicare Part B claims use the term “ordering/referring provider” to denote the person who ordered, referred, or certified an item or service reported in that claim. To view the comments to the Final Rule, visit https://www.gpo.gov/fdsys/pkg/FR- 2012-04-27/pdf/2012-9994.pdf on the Internet. Use the following technically correct terms:

1. A provider “orders” non-physician items or services for the beneficiary, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), clinical laboratory services, or imaging services; and

2. A provider “certifies” home health services for a beneficiary. The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. CMS uses the term “ordered/referred” on its website and in educational materials directed to a broad provider audience.


The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) of the Act. All claims for Medicare covered services and items that are the result of physician’s order or referral shall include the  ordering/referring physician’s name. See Items 17a and 17b below for further guidance on reporting the referring/ordering provider’s NPI.

The following services/situations require the submission of the referring/ordering provider
information:
  •  Medicare covered services and items that are the result of a physician's order or referral;
  •  Parenteral and enteral nutrition;
  •  Immunosuppressive drug claims;
  •  Hepatitis B claims;
  •  Diagnostic laboratory services;
  •  Diagnostic radiology services;
  •  Portable x-ray services;
  •  Consultative services;
  •  Durable medical equipment
  •  When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);
  •  When a service is incident to the service of a physician or non-physician practitioner,the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17;
  •  When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner;


Ordering/Referring Services

If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office). While a physician order is not required to be signed, the physician must clearly document in the medical record his or her intent that the test be performed.

Providers who order diagnostic services for Medicare patients must also maintain documentation of the order/intent to order and medical necessity of the service(s) in the patient’s medical record. Keep this information available and submit it, along with the test results, upon request for a Medicare claim review. For information on “access to documentation,” refer to MLN Matters® Article MM9112 Clarification of Ordering and Certifying Documentation Maintenance Requirements.


Cooperation among ordering/referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials

Laboratory Billing – Referring Provider 

The ordering or referring provider’s name should be included on all CMS-1500 claims submitted with laboratory services in boxes 17, 17a, 17b or its electronic equivalent.


Laboratory Billing – Referring Provider NPI BOX 17



How Should I Report Ordering/Referring Physicians or Non-Physicians on Claims?

For Medicare Part B and DMEPOS providers, the ordering/referring information should be reported on the line, “Name of Referring Provider or Other Source,” along with the referring provider’s NPI (lines 17 and 17b of Form CMS-1500). For Medicare Part A HHAs, the ordering/referring information should be reported on the line, “Attending,” along with the attending provider’s NPI (line 76 of Form CMS-1450). The ordering/referring provider’s name must match the name found in the provider’s PECOS enrollment record.

Why Do I Currently Receive Informational Messages when I Submit a Claim for Ordering/Referring?

Laboratories, imaging centers, DMEPOS suppliers, and HHAs receive this message if the ordering/referring or attending physician/non-physician practitioner reported on the claim does not meet the three basic requirements for ordering/referring. In the future, Medicare Contractors (Part A/B Medicare Administrative Contractors [MACs], Durable Medical Equipment [DME] MACs, and Part A Regional Home Health Intermediaries [RHHIs]) will activate automatic edits to deny claims that do not meet the three basic requirements for ordering/referring providers. CMS will give providers at least 60 days notice before the ordering/referring provider claim edit is applied. Physicians and others who are eligible to order/refer items or services need to be enrolled in Medicare and must be of a specialty that is eligible to order and refer. If the billed service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, but is not enrolled in Medicare, the claim will not be paid. In addition, if the ordering/referring provider is on the claim, but is not of a specialty that is eligible to order/refer, the claim will not be paid. CMS encourages laboratories, imaging centers, DMEPOS suppliers, and HHAs to work with their ordering/referring providers to ensure they are prepared for this change.

1. What are the ordering and referring edits?

The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B clinical laboratory and imaging, DME, and Part A HHA claims) (1) has a current Medicare enrollment record and contains a valid NPI (the name and NPI must match), and (2) is of a provider type that is eligible to order or refer for Medicare beneficiaries (see list above).


2. Why did Medicare implement these edits?

These edits help protect Medicare beneficiaries and the integrity of the Medicare program. 

3. How and when will these edits be implemented* 

These edits were implemented in two phases:

Phase 1 -Informational messaging: Began October 5, 2009, to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:


For Part B providers and suppliers who submit claims to carriers:

N264 Missing/incomplete/invalid ordering provider name
N265 Missing/incomplete/invalid ordering provider primary identifier

For adjusted claims, the Claims Adjustment Reason Code (CARC) code 16 (Claim/service lacks information which is needed for adjudication.) is used.

DME suppliers who submit claims to carriers (applicable to 5010 edits):


N544

Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future For Part A HHA providers who order and refer, the claims system initially processed the claim and added the following remark message: 

N272 Missing/incomplete/invalid other payer attending provider identifier

For adjusted claims the CARC code 16 and/or the RARC code N272 was used.

CMS has taken actions to reduce the number of informational messages. In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physicians and non-physician practitioners who are eligible to order and refer but who had not updated their PECOS enrollment records with their NPIs.1 On January 28, 2010, CMS made available to the public, via the Downloads section of the “Ordering Referring Report” page on the Medicare provider/supplier enrollment website, a file containing the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/specialty that is eligible to order and refer. The file, called the Ordering Referring Report, lists, in alphabetical order based on last name, the NPI and the name (last name, first name) of the physician or non-physician practitioner. To keep the available information up to date, CMS will replace the Report twice a week. At any given time, only one Report (the most current) will be available for downloading. To learn more about the Report and to download it, go to https://data.cms.gov on the CMS website.


Phase 2: Effective January 6, 2014, CMS will turn on the Phase 2 edits. In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.

Below are the denial edits for Part B providers and suppliers who submit claims to Part A/B MACs, including DME MACs:
254D or 001L

Referring/Ordering Provider Not Allowed To Refer/Order

255D or 002L

Referring/Ordering Provider Mismatch

CARC code 16 or 183 and/or the RARC code N264, N574, N575 and MA13 shall be used for denied or adjusted claims.

Claims submitted identifying an ordering/referring provider and the required matching NPI is missing (edit 289D) will continue to be rejected. CARC code 16 and/or the RARC code N265, N276 and MA13 shall be used for rejected claims due to the missing required matching NPI.

Below are the denial edits for Part A HHA providers who submit claims: 37236 This reason code will assign when:

* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on

* The type of bill is '32' or '33'

* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from EPCOS or the specialty code is not a valid eligible code




37237 This reason code will assign when:

* The statement “From” date on the claim is on or after the date the phase 2 edits are turned on

* The type of bill is '32' or '33'

* The type of bill frequency code is '7' or 'F-P'

* Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code

Effect of Edits on Providers

I order and refer. How will I know if I need to take any sort of action with respect to these two edits*
In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you, the ordering/referring provider, need to ensure that:

a . You have a current Medicare enrollment record.

* If you are not sure you are enrolled in Medicare, you may:

i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in Medicare and it contains your NPI;

ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in Medicare and it contains the NPI; or

iii . Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do not have an enrollment record in Medicare). 

iv . If you choose iii, please read the information on the Medicare provider/supplier enrollment web page about Internet-based PECOS before you begin.


b . If you do not have an enrollment record in Medicare.

* You need to submit either an electronic application through the use of internet-based PECOS or a paper enrollment application to Medicare.

i. For paper applications - fill it out, sign and date it, and mail it, along with any required supporting paper documentation, to your designated Medicare enrollment contractor.

ii. For electronic applications – complete the online submittal process and either e-sign or mail a printed, signed, and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor.






iii . In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement.

iv . If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web page to learn more about the web-based system before you attempt to use it. Go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html, click on “Internet-based PECOS” on the left-hand side, and read the information that has been posted there. Download and read the documents in the Downloads Section on that page that relate to physicians and non-physician practitioners. A link to Internet-based PECOS is included on that web page.

v. If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS or by completing the paper enrollment application (CMS-855O). Enrollment applications are available via internet-based PECOS or .pdf for downloading from the CMS forms page (http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/index.html).



c. You are an opt-out physician and would like to order and refer services. What should you do*
If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit). Note, however, that prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician/practitioner opt-out affidavits were only effective for 2 years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If physicians and practitioners that file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative Contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.



d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries. When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order or refer in the Medicare program.


e . I bill Medicare for items and services that were ordered or referred. How can I be sure that my claims for these items and services will pass the Ordering/Referring Provider edits?

* You need to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program. 


If you are not sure that the physician or non-physician practitioner who is ordering or referring items or services meets those criteria, it is recommended that you check the Ordering Referring Report described earlier in this article.

* Ensure you are correctly spelling the Ordering/Referring Provider’s name.

* If you furnished items or services from an order or referral from someone on the Ordering Referring Report, your claim should pass the Ordering/Referring Provider edits.

* The Ordering Referring Report will be replaced twice a week to ensure it is current. It is possible that you may receive an order or a referral from a physician or non-physician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next Report.



f. Make sure your claims are properly completed.

* On paper claims (CMS-1500), in item 17, only include the first and last name as it appears on the Ordering and Referring file found on CMS.gov.

* On paper claims (CMS-1450), you would capture the attending physician’s last name, first name and NPI on that form in the applicable sections. On the most recent form it would be fields in FL 76.

* On paper claims (CMS-1500 and CMS-1450), do not enter “nicknames”, credentials (e.g., “Dr.”, “MD”, “RPNA”, etc.) or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits.

* Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral.

* Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1 (person). Organizations (qualifier 2) cannot order and refer.

If there are additional questions about the informational messages, Billing Providers should contact their local A/B MAC, or DME MAC.

Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services including home health, DMEPOS, imaging and clinical laboratory.



g. What if my claim is denied inappropriately?

If your claim did not initially pass the Ordering/Referring provider edits, you may file an appeal through the standard claims appeals process or work through your A/B MAC or DME MAC.


h. How will the technical vs. professional components of imaging services be affected by the edits* Consistent with the Affordable Care Act and 42 CFR 424.507, suppliers submitting claims for imaging services must identify the ordering or referring physician or practitioner. Imaging suppliers covered by this requirement include the following: IDTFs, mammography centers, portable x-ray facilities and radiation therapy centers. The rule applies to the technical component of imaging services, and the professional component will be excluded from the edits. However, if billing globally, both components will be impacted by the edits and the entire claim will deny if it doesn’t meet the ordering and referring requirements. It is recommended that providers and suppliers bill the global claims separately to prevent a denial for the professional component.

i. Are the Phase 2 edits based on date of service or date of claim receipt* The Phase 2 edits are effective for claims with dates of service on or after January 6, 2014.

j. A Medicare beneficiary was ordered a 13-month DME capped rental item. Medicare has paid claims for rental months 1 and 2. The equipment is in the 3rd rental month at the time the Phase 2 denial edits are implemented. The provider who ordered the item has been deactivated. How will the remaining claims be handled*

Claims for capped rental items will continue to be paid for up to 13 months from the physician’s date of deactivation to  allow coverage for the duration of the capped rental period.

Ordering/Referring Physician Checklist for Home Health Agencies

To receive Medicare reimbursement for home health services, the physician that ordered/ referred the patient for home health care must be enrolled in the Medicare program, and have an enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS). Fiscal Intermediary Standard System (FISS) edits are in place to ensure that the attending and certifying physician information reported on a home health claim meets this requirement. To avoid claim denials, follow the steps below.

Step 1: Verify the physician’s NPI, last name, and first name using the “Medicare Ordering and Referring File” available at https://data.cms.gov/

NOTE: This file is updated by CMS twice a week, so it is important to verify the physician information prior to submitting each billing transaction.

Step 2: Home health services must be ordered or referred by a Doctor of Medicine (MD), Doctor of Osteopathy (DO) or Doctor of Podiatric Medicine (DPM). To verify the credentials of the ordering/referring physician, search the physician’s NPI using the NPPES website, https://npiregistry.cms.hhs.gov/. Refer to Page 3 of this tool for a list of valid home health ordering/referring specialty codes.

Step 3: Prior to submitting the Request for Anticipated Payment (RAP) and claim, verify the following information matches the Ordering/Referring File exactly.

• The NPI of the physician.
• The first four letters of the physician’s last name
• The first letter of the physician’s first name


COMPLYING WITH DOCUMENTATION REQUIREMENTS FOR LABORATORY SERVICES

The majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were due to insufficient documentation. Insufficient documentation means that something was missing from the medical records. For example, the medical record was missing:

** Documentation to support intent to order, such as a signed progress note, signed office visit note, or signed physician order

** Documentation to support the medical necessity of ordered services The Medicare Learning Network® (MLN) and the CERT Part A and Part B (A/B) Medicare Administrative Contractor (MAC) Outreach & Education Task Force developed this publication. The CERT Program estimates improper payments in the Medicare FFS Program. The CERT Program reviews a random sample of all Medicare FFS claims to determine if they met Medicare coverage, coding, and billing rules. Once the CERT Program identifies a claim as part of the sample, it requests the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim. Medical review professionals review the submitted documentation to see if the claim was paid or denied appropriately.

Document Requirements

For more information about signature requirements and attestation statements, refer to Complying with Medicare Signature Requirements.

** The physician who is treating the beneficiary must order all diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests. The physician who treats the beneficiary is the physician who furnishes a consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician are not reasonable and necessary.

** When completing progress notes, the physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself does not support intent to order).

** Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records in response to a request for medical records.

** Keep these records available upon request: Progress notes or office notes

Physician order/intent to order Laboratory results

Attestation/signature log for illegible signature(s) Signature Requirements

** Unsigned physician orders or unsigned requisitions alone do not support physician intent to order.

** Physicians should sign all orders for diagnostic services to avoid potential denials.

** If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. For an example of a signature attestation statement, visit the CERT Provider website. If the signature is illegible, an attestation statement or signature log is acceptable.

** Attestation statements are not acceptable for unsigned physician orders/requisitions.




Medicare Enrollment Guidelines for Ordering/Referring Providers

Ordering/Referring Terms

Medicare Part B claims use the term “ordering/referring provider” to identify the person who ordered, referred, or certified an item or service reported in that claim.

The following are technically correct terms:

1. A provider “orders” non-physician items or services for the beneficiary, such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); clinical laboratory services; or imaging services.

2. A provider “certifies” home health services for a beneficiary. The health care industry uses the terms “ordered,” “referred,” and “certified” interchangeably. To view comments about this terminology, read the Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements Final Rule.
.
Who Are Ordering/Referring Providers?

Any Medicare-enrolled Part B provider, DMEPOS supplier, or Part A Home Health Agency (HHA) provider may submit claims with ordering/referring information.

The ordering/referring provider must meet these three basic requirements:

1. Have an individual National Provider Identifier (NPI)

NOTE Organizational NPIs do not qualify and cannot order/refer.
2. Be enrolled in Medicare in either an “approved” or an “opt-out” status
3. Be of a specialty type that is eligible to order/refer Denial of Ordering/Referring Claims

MACs deny the following claims if they lack a valid individual NPI:
• Claims from clinical laboratories for ordered tests
• Claims from imaging centers for ordered imaging procedures
• Claims from suppliers of DMEPOS for ordered DMEPOS
• Claims from Part A HHAs

If a billed service requires an ordering/referring provider and one is not present on the claim, the MAC will deny the claim. In addition to a valid individual NPI, the claim must contain the ordering/referring provider’s name as it appears in the Provider Enrollment, Chain, and Ownership System (PECOS).


How Do I Enroll in Medicare as an Ordering/Referring Provider?

CMS allows certain physicians and other eligible NPPs to enroll in Medicare for the sole purpose of ordering/referring specific items or services for Medicare beneficiaries. Those who enroll as ordering/referring providers only may not seek or receive reimbursement from Medicare for services they furnish. They do not have billing privileges for submitting claims to Medicare directly for services provided to Medicare beneficiaries.


Medicare Ordering/Referring Provider Requirements


The Affordable Care Act, Section 6405, requires physicians and other eligible Non-Physician Practitioners (NPPs) to enroll in the Medicare Program to order/refer items or services for Medicare beneficiaries, including those physicians and other eligible NPPs who do not and will not send claims to a Medicare Contractor for the services they furnish.

Effective May 1, 2013, Medicare will deny claims for all covered Medicare Part B, durable medical equipment, orthotics, and supplies (DMEPOS), and Part A home health agency (HHA) services when the ordering/referring provider is not enrolled in Medicare and the claim does not list the national provider identification (NPI) number for the ordering or referring provider.

Providers eligible to order/refer services:

* Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry and optometrists)
* Physician Assistants
* Clinical Nurse Specialists
* Nurse Practitioners
* Clinical Psychologists
* Interns, Residents and Fellows
* Certified Nurse Midwives
* Clinical Social Workers

This includes interns, residents, fellows, and those who are employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD), or the Public Health Service (PHS) who order or refer items or services for Medicare beneficiaries. State-licensed residents may enroll to order or refer and may be listed on claims. Claims from unlicensed interns and residents may still specify the name and NPI of the teaching physician. If States provide provisional licenses or otherwise permit residents to practice or order and refer services, interns and residents are allowed to enroll to order and refer consistent with State law.

Limitations:

* Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.

* Optometrists may only order and refer DMEPOS products/services, and laboratory  and X-Ray services payable under Medicare Part B. Providers eligible to order/refer for Medicare Part A Home Health Agency (HHA) services:

* Doctors of Medicine or Osteopathy
* Doctors of Podiatric Medicine 

Claims for HHA services ordered by any other practitioner specialty will be denied.

Informational Messages

Providers billing services that require the reporting of an ordering/referring physician or NPP, including laboratories, imaging centers, DMEPOS suppliers, and HHAs get an informational message if the ordering/referring or attending physician/NPP reported on the claim does not meet the three basic requirements for ordering/referring. Currently, informational messages alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjusted claim that did not pass the edits indicates the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:

For Part B providers who submit claims:
N264 Missing/incomplete/invalid ordering provider name
N265 Missing/incomplete/invalid ordering provider primary identifier


For DME suppliers who submit claims:  

N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future


For Part A HHA providers who submit claims:

N272 Missing/incomplete/invalid other payer attending provider identifier If you have received these messages on your remittance advice, the physician/non-physician practitioner that ordered/referred the services may not:

* Be enrolled in Medicare, either in an approved or an opt-out status
* Have an Individual National Provider Identifier (NPI)
* Be of a specialty type that is eligible to order and refer On and after May 1, 2013 your claims will be denied if the physician/NPP thatordered/referred the services you billed does not meet the above requirements


Denial Messages

Effective May 1, 2013, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.

For Part B providers and DME suppliers who submit claims:
254D Referring/Ordering Provider Not Allowed To Refer
255D Referring/Ordering Provider Mismatch
289D Referring/Ordering Provider NPI Required
CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.



Billing provider type Billing provider type descriptions

18 Private duty nursing
36 Ambulatory surgery center
37 Independent lab
50 Hearing aid dealer
52 Optician
54 Pharmacy: all crossover services billed
70 Audiologist
76 Multi-therapy agency
79 Speech language pathologist
86 X-ray/miscellaneous supplier
87 Physical therapy
88 Occupational therapist
90 Durable medical equipment (DME)


Provider type Provider type descriptions

60 Dentist
64 Physician, individual
74 Certified registered nurse anesthetist
77 Optometrist
78 Certified nurse practitioner
80 Podiatrist
85 Chiropractor
95 Physician assistant

Billing provider NPI/taxonomy combination indicates the provider type is 65 (physician group). The claim lists a Referring provider with a provider type of 80 (podiatrist).

o If the Referring provider information is on the claim, Anthem will edit the data even if the Referring provider is not required for billing provider type 65.

* The claim will be accepted.

• Billing provider NPI/taxonomy combination indicates the provider type is 35 (rural health clinic). The claim lists a Referring provider with a provider type of 52 (optician).

o If the Referring provider information is on the claim, Anthem will edit the data even if the Referring provider is not required for billing provider type 35.

* The claim will not be accepted.

cms 1500 paper claim, font, size

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, etc.);
• 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.

Tuesday, June 22, 2010

Tips for submitting error-free paper claims

TROUBLESHOOTING BASICS:
• Use only an original red-ink-on-white-paper Form CMS-1500 claim form.
• Use dark ink
.• Do not print, hand-write, or stamp any extraneous data on the form.
• Do not staple, clip, or tape anything to the Form CMS-1500 claim form.
• Remove pin-fed edges at side perforations
.• Use only lift-off correction tape to make corrections.
• Place all necessary documentation in the envelope with the Form CMS-1500 claim form.


FORMAT HINTS:
• Do not use italics or script.
• Do not use dollar signs, decimals, or punctuation.
• Use only upper-case (CAPITAL) letters.
• Use 10- or 12-pitch (pica) characters and standard dot matrix fonts.
• Do not include titles (e.g., Dr., Mr., Mrs., Rev., M.D.) as part of the beneficiary’s name.
• Enter all information on the same horizontal plane within the designated field
.• Follow the correct Health Insurance Claim Number (HICN) format. No hyphens or dashes should be used. The alpha prefix or suffix is part of the HICN and should not be omitted. Be especially careful with spouses who have a similar HICN with a different alpha prefix or suffix.
• Ensure data is in the appropriate field and does not overlap into other fields
.• Use an individual’s name in the provider signature field, not a facility or practice name.

CMS 1500 - Claim error

Claim Errors

“Unprocessable claims” is a term used by Medicare for claims that contain certain incomplete or invalid
information and are returned to the provider. For example, a claim may be returned as unprocessable because the contractor requires additional information or a correction to the submitted claim data. Because there is no initial determination on the claim, health care professionals and suppliers who submit unprocessable claims have no appeal rights. The phrase “return as unprocessable” does not mean that in every case a claim is physically returned. Contractors may return the actual unprocessable claim (or a copy of it) to the health care professional or supplier with a letter of explanation or generate a Remittance Advice (RA), which we will discuss later in this fact sheet. Some contractors may suspend a claim that contains incomplete or invalid information, and then provide notice of the errors to the provider and afford a period of time for corrections to be submitted. When adequate corrections are submitted, the contractor will then resume processing of the claim.

Providers need to be aware that an unprocessable claim that has been returned for correction and resubmission does not toll the timely filing period. A correct claim must be resubmitted within the timely filing period. Where a contractor has suspended a claim and allowed a period for submission of corrections, the timely filing requirements will have been met if the corrections are received within the allotted time.Form CMS-1500 incomplete and invalid claims processing guidelines may be found in the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c01.pdf

What is CMS 1500 AND WHO can submit paper claim to Medicare

What is the Form CMS-1500?

The Form CMS-1500 is the standard paper claim form used by health care professionals and suppliers to bill Medicare Carriers or Part A/B and Durable Medical Equipment Medicare Administrative Contractors (A/B MACs and DME MACs).

A claim is a request for payment of Medicare benefits for services furnished by a health care professional or supplier. Claims must be submitted within one year from the date of service and Medicare beneficiaries cannot be charged for completing or filing a claim. Offenders may be subject to penalty for violations.


Exceptions to Mandatory Electronic Claim Submission
The Administrative Simplification Compliance Act (ASCA) prohibits payment of services or supplies not submitted to Medicare electronically, with limited exceptions. Medicare will receive and process paper claims from health care professionals and suppliers who meet the exceptions to the requirements set forth in the ASCA.

Some circumstances always meet the exception criteria

Health care professionals and suppliers that experience one of these unusual circumstances are automatically waived from the electronic claim submission requirement for either the indicated claim type or the period when the unusual circumstance exists.

A listing of these definitive exceptions and the latest information on CMS regulations regarding the limited acceptance of paper claims in lieu of electronic billing may be found at
http://www.cms.gov/ElectronicBillingEDITrans/05_ASCASelfAssessment.asp on the CMS website. These circumstances include:

• A physician, practitioner, or supplier that bills a Medicare Carrier, A/B MAC, or DME MAC and has fewer than 10 Full-Time Equivalent (FTE) employees.

• A health care professional or supplier experiencing a disruption in electricity and communication connections that is beyond its control.

Health care professionals and suppliers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request to their contractor. If one of these circumstances applies, they may submit claims to Medicare on paper or via other non-electronic means.

FILING CMS 1500 CLAIM - TIPS

Additional Tips on Filing

Here’s other important information you need to know before you begin filling out
your form:

Use current CPT (Current Procedural Terminology) of the American
Medical Association, ICD 9 (International Classification of Diseases)
Diagnostic Codes, or HCPCS (Healthcare Common Procedure Coding
System) Codes maintained by the Centers for Medicare and Medicaid
Services. Or,

Use the Procedure Codes in Chapter III of the MaineCare Benefits Manual
policy section under which you bill. You may access these codes at the
following website: http://www.maine.gov/sos/cec/rules/10/ch101.htm

The required format for a birth date is MMDDYYYY. (Example: January
19, 1947 = 01191947.)

Whether you fill in your claim form by typing, computer, or handwriting,
keep all information within the designated boxes. Do not overlap
information into other fields. If the information is not in the required fields
your claims will be returned to you with a cover letter stating that the
information is not aligned correctly

Denial list - CMS 1500 data missing in particular field

1a - CMS 1500 - Field
A claim lacks a valid (or contains an invalid) Health Insurance Claim Number (HICN).
MA61

2
A claim lacks a valid (or contains an invalid) patient’s last name and first name as seen on the patient’s Medicare card.
MA36

11
A claim does not indicate whether or not a primary insurer to Medicare exists.
MA83 or MA92

12
A claim lacks a valid (or contains an invalid) patient or authorized person’s signature.
MA75

24a
A claim lacks a valid (or contains an invalid) “from” date of service.
M52

24b
A claim lacks a valid (or contains an invalid) place of service for each detail.
M77

24d
A claims lacks a valid (or contains an invalid) procedure or HCPCS code.
M20 or M51

24f
A claim lacks a charge for each listed service.
M79

24g
If the claim does not indicate at least one day or unit
M53

31
A claim lacks a signature from a provider of service or supplier, or their representative.
MA70 or MA81

33
A claim does not contain a billing name, address, ZIP code and telephone number of a provider or supplier of service and a valid NPI in Item 33a.
N256, N257, N258 or MA112

33a
A claim lacks the NPI of the billing provider, supplier or group.
N257 or MA112

Returned or unprocessable claim - cms 1500

Returned Claims
Please correct “returned” claims promptly because only when this is done will a provider have met his legal obligation for submitting a Medicare claim.

Definitions
Unprocessable Claim – Any claim with incomplete or missing required information, or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Incomplete Information – Missing, required or conditional information on a claim (e.g., no National Provider Identifier (NPI)).

Invalid Information – Complete required or conditional information on a claim that is illogical or incorrect (e.g., incorrect NPI) or no longer in effect (e.g., an expired number).

Required – Any data element that is needed in order to process a claim (e.g., provider name, date of service).

Not Required – Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., patient’s marital status).

Conditional – Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, the insured’s name must be entered on the claim).

Friday, June 11, 2010

Provider specialty code

Nonphysician Practitioner, Supplier, and Provider Specialty Codes

The following list of 2-digit codes and narrative describe the kind of medicine non-physician practitioners or other healthcare providers/suppliers practice.

Code  Non-physician Practitioner/Supplier/Provider Specialty

15       Speech Language Pathologists
32       Anesthesiologist Assistant
42       Certified Nurse Midwife (effective July 1, 1988)
43       Certified Registered Nurse Anesthetist (CRNA)
45       Mammography Screening Center
47       Independent Diagnostic Testing Facility (IDTF)
49      Ambulatory Surgical Center
50      Nurse Practitioner
51      Medical supply company with orthotic personnel certified by an accrediting organization
52      Medical supply company with prosthetic personnel certified by an accrediting organization
53      Medical supply company with prosthetic/orthotic personnel certifiedby an accrediting organization
54      Medical supply company not included in 51, 52, or 53
55      Individual orthotic personnel certified by an accrediting organization
56      Individual prosthetic personnel certified by an accrediting organization
57      Individual prosthetic/orthotic personnel certified by an accrediting organization
58      Medical Supply Company with registered pharmacist
59      Ambulance Service Supplier, e.g., private ambulance companies, funeral homes
60      Public Health or Welfare Agencies (Federal, State, and local)
61      Voluntary Health or Charitable Agencies (e.g., National Cancer Society, National Heart Association, Catholic Charities)
62      Clinical Psychologist (Billing Independently)
63      Portable X-Ray Supplier (Billing Independently)
64      Audiologist (Billing Independently)
65     Physical Therapist in Private Practice
67     Occupational Therapist in Private Practice
68     Clinical Psychologist
69     Clinical Laboratory (Billing Independently)
71     Registered Dietician/Nutrition Professional
73     Mass Immunization Roster Billers (Mass Immunizers have to roster bill assigned claims and can only bill for immunizations)
74     Radiation Therapy Centers
75     Slide Preparation Facilities
80     Licensed Clinical Social Worker
87     All other suppliers, e.g., Drug Stores
88     Unknown Supplier/Provider
89     Certified Clinical Nurse Specialist
95     Available
96     Optician
97     Physician Assistant
A0    Hospital
A1    Skilled Nursing Facility
A2    Intermediate Care Nursing Facility
A3    Nursing Facility, Other
A4    Home Health Agency
A5    Pharmacy
A6    Medical Supply Company with Respiratory Therapist
A7    Department Store
A8    Grocery Store
B2     Pedorthic Personnel
B3     Medical Supply Company with Pedorthic Personnel
B4     Rehabilitation Agency

NOTE: Specialty Code Use for Service in an Independent Laboratory. For services performed in an independent laboratory, show the specialty code of the physician ordering the x-rays and requesting payment. If the independent laboratory requests payment, use type of supplier code "69".

MTUS indicator of CMS 1500

Methodology for Coding Number of Services, MTUS Count and MTUS Indicator Fields

The following instructions should be used as a guide for coding the number of services, MTUS Count and MTUS Indicator fields on the Part B Physician/Supplier Claim. These fields are documented in the CMS National Claims History Data Dictionary as CWFB_SRVC_CNT, CWFB_MTUS_CNT, and CWFB_MTUS_IND_CD, respectively.

Services not falling into examples B, C, E, or F should be coded as shown in example D (services/pricing units).

A. No Allowed Services – (CWFB_MTUS_IND_CD = 0)

For claims reporting no allowed services, the following example should be used to code the line item:
A total of 2 visits was reported for HCPCS code 99211: Office or other outpatient visit for the management of an established patient. Both services were denied.
Number of services: 2 (furnished)
                              MTUS (services): 0 (allowed)
                              MTUS indicator: 0

B. Ambulance Miles - (CWFB_MTUS_IND_CD = 1)

For claims reporting ambulance miles, the following example should be used to code the line item:
Mileage Reporting: A total of 10 miles (1 trip) was reported for HCPCS code A0425: Ground mileage, per statute mile.
                          Number of services: 10
                          MTUS (miles): 10
                         MTUS indicator: 1

C. Anesthesia Time Units - (CWFB_MTUS_IND_CD = 2)

For claims reporting anesthesia time units in 15-minute periods or fractions of 15-minute periods, the following example should be used to code the line item:
A total of 1 allowed service is reported for HCPCS code 00142: Anesthesia for procedures on eye; lens surgery. The anesthesiologist attended the patient for 35 minutes.
                   Number of services: 1
                  MTUS (time units): 23 (one decimal point implied) *
                  MTUS indicator: 2
* Two 15-minute periods + 1/3 of a 15-minute period equals 2.3

D. Services/Pricing Units - (CWFB_MTUS_IND_CD = 3)

For claims reporting a service or pricing unit, the following examples should be used to code the line item:

Example 1-A total of 2 visits was reported for HCPCS code 99211: Office or other outpatient visit for the management of an established patient.
                   Number of services: 2
                   MTUS (services): 2
                   MTUS indicator: 3

Example 2 - A total of 500 milligrams was administered for HCPCS code J0120: Injection, Tetracycline, up to 250 mg.
NOTE: The number of milligrams should not be reported in the service or MTUS fields. Instead, report the number of pricing units. In this case, up to 250 mg equals 1 unit/service. Thus, 500 mg equals 2 units/services.
                    Number of services: 2
                    MTUS (services): 2
                    MTUS indicator: 3

Example 3-A total of 24 cans was purchased, each containing 300 calories for HCPCS code B4150: Enteral Formulae, 100 calories.
NOTE: Neither number of cans nor the number of calories should be reported in the services or MTUS fields. Instead, report the number of pricing units. In this case, 100 calories equals 1 unit/service. Thus, 24 cans * 300 calories / 100 calories equals 72 units/services.
                         Number of services: 72
                        MTUS (services): 72
                        MTUS indicator: 3


E. Oxygen Services - (CWFB_MTUS_IND_CD = 4)

For claims reporting oxygen units, the following example should be used to code the line item:
A total of 2 allowed services was reported for HCPCS code E0441: Oxygen contents, gaseous, 1 month’s supply = 1 unit. The claim reported a 2 month’s supply of oxygen.
                               Number of services: 2
                               MTUS: 2
                               MTUS indicator: 4

F. Blood Services - (CWFB_MTUS_IND_CD = 5)
For claims reporting blood units, the following example should be used to code the line item:
A total of 6 units of blood (services) was furnished for HCPCS code P9010: Blood (whole), for transfusion, per unit. Two units were denied.
                            Number of services: 6 (furnished)
                            MTUS (units): 4 (allowed)
                            MTUS indicator: 5

Thursday, June 10, 2010

Miles, Times, Units, Services (MTUS) Indicator Field of CMS 1500

Miles/Times/Units/Services (MTUS)

Miles/Times/Units/Services (MTUS) count and MTUS indicator fields are on Part B Physician/Supplier Claims. These fields are documented in the CMS National Claims History Data Dictionary.

Standard systems are to put MTUS count and MTUS indicators on all claims at the line item level.
The purpose of the MTUS Count Field on the line item is to document additional information reflecting certain volumes related to indicators. In most cases, the value in this field will be the same as in the Service Count Field on the line item; however, for services such as anesthesia the field values will differ. In this case, the service count field will likely contain a value of 1 for the occurrence of the surgery while the MTUS Count Field will contain the actual time units that the anesthesiologist spent with the patient in 15 minute increments or a fraction thereof.

The purpose of the Miles, Times, Units, Services (MTUS) Indicator Field is to indicate what the value entered into the MTUS Count Field means. There are 6 indicator values, as follows:

0 - No allowed services
1 - Ambulance transportation miles
2 - Anesthesia Time Units
3 - Services
4 - Oxygen units
5 - Units of Blood

What is the importance of accept assignment?

Field 27 

Item 27 - Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap payment authorization is given in item 13, the provider of service or supplier shall also be a Medicare participating provider of service or supplier and accept assignment of Medicare benefits for all covered charges for all patients.

The following providers of service/suppliers and claims can only be paid on an assignment basis:
• Clinical diagnostic laboratoservices;
• Physician services to individuals dually entitledry  to Medicare and Medicaid;
• Participating physician/supplier services;
• Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, and clinical social workers;
• Ambulatory surgical center services for covered ASC procedures;
• Home dialysis supplies and equipment paid under Method II;
• Ambulance services;
• Drugs and biologicals; and
• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.

Signature of provider - Box 31 CMS 1500

Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and either the 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alpha-numeric date (e.g., January 1, 1998) the form was signed.

In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. When the ordering physician or non-physician practitioner is not supervising the service, then enter the signature of the physician or non-physician practitioner providing the direct supervision in item 31.

NOTE: This is a required field, however the claim can be processed if the following is true. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature.

Wednesday, June 9, 2010

How to Filing Form CMS-1500 - Tips to submit claim

Filing Form CMS-1500

Medicare Part B physicians may use the red-printed Form CMS-1500 to file various health insurance claims to private insurers and government programs. However, payment for paper claims takes substantially longer than payment for electronically submitted claims. Generally, electronic claims can be paid 14 days after submission, as opposed to paper claims that process in about four weeks. 

How Paper Claim Submission 

Works When filing paper claims, physicians must type or machine-print all mandated claim fields on the red-printed Form CMS-1500 and mail it to the local carrier. Some carriers may be able to accept a black and white copy of Form CMS-1500. Other carriers may not accept black and white copies of the form if they are using Optical Character Recognition (OCR) equipment to process the form.

Optical Character Recognition 

Carriers that process claims with OCR, use an automated scanning process similar to scanners that read price labels in grocery stores. OCR claims processing is faster and more accurate than systems requiring manual input. However, to work properly, OCR must accurately read and interpret the characters entered in each field. It reads only typed or machine-printed data. Only an original, red and white Form CMS-1500 may be submitted. Black and white photocopies cannot be machine read and will be returned. 

After claims information is scanned, it is transmitted to the claims processing system, where it is validated. 

To ensure accurate, quick claim processing, the following guidelines must be followed: 

*Do not staple, clip, or tape anything to Form CMS-1500
*Place all necessary documentation in the envelope with Form CMS-1500 
* Put the patient ’ s name and Medicare number on each piece of documentation submitted 
* Use dark ink 
* Use only upper-case (CAPITAL) letters 
* Use 10 or 12 pitch (pica) characters and standard dot matrix fonts 
* Do not mix character fonts on the same form 
* Do not use italics or script 
* Avoid using old or worn print bands or ribbons
* Do not use dollar signs, decimals, or punctuation 
* Enter all information on the same horizontal plane within the designated field 
* Do not print, hand-write, or stamp any extraneous data on the form 
* Use only lift-off correction tape to make corrections 
* Ensure data is in the appropriate field and does not overlap into other fields 
* Remove pin-fed edges at side perforations 
* Use only an original red-ink-on-white-paper Form CMS-1500




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