Monday, December 15, 2014

What are 837 I format and cms 1450 claim

The 837I (Institutional) is the standard format used by institutional providers to transmit health care claims electronically. The Form CMS-1450, also known as the UB-04, is the standard claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claimis allowed. In addition to billing Medicare, the 837I and Form CMS-1450 may be suitable for billing various
government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the form as the Form CMS-1450 and the form is referred to throughout this fact sheet as the CMS-1450.

Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).


The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837I (Institutional) Version 5010A2 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet.

ANSI = American National Standards Institute
ASC = Accredited Standards Committee
X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions
837 = Standard format for transmitting health care claims electronically
I = Institutional version of the 837 electronic format
Version 5010A2 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for institutional providers.
The National Uniform Billing Committee (NUBC) makes their UB-04 manual available through their website. This manual contains the updated specifications for the data elements and codes included on the CMS-1450 and used in the 837I transaction standard. Medicare FFS Contractors may include a crosswalk between the ASC X12N 837I and the CMS-1450 on their websites

When Does Medicare Accept a Hard Copy Claim Form?

Initial claims for payment under Medicare must be submitted electronically unless an institutional provider qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

Before submitting a hard copy claim, providers should self-assess to determine if they meet one
or more of the ASCA exceptions. For example, institutional providers that have fewer than 25 Full-Time Equivalent (FTE) employees and bill a Medicare FFS Contractor are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If an institutional provider meets an exception, there is no need to submit a waiver request.

There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of an institutional provider’s staff prevents use of a computer for electronic submission of claims. Institutional providers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their Medicare FFS Contractor.

Timely Filing

The timely filing period for both paper and electronic Medicare claims is 12 months, or one calendar year, after the date of service.

Claims are denied if they arrive after the deadline date. When a claim is denied for having been filed after the timely filing period, such a denial does not constitute an initial determination. As such, the determination that a claim was not filed timely is not subject to appeal.

In general, the start date for determining the 12-month timely filing period is the date of service or ‘From’ date on the claim. Medicare uses the line item ‘Through’ date to determine the date of service for claims filing timeliness for claims that include span dates of service (i.e., a ‘From’ and ‘Through’ date span on the claim).
Medicare regulations allow exceptions to the 12-month time limit for filing claims.

Where to Submit FFS Claims

Claims for services must be submitted to the appropriate Medicare FFS Contractor. Contact the Medicare FFS Contractor by referencing the
Provider Compliance Group Interactive Map on the CMS website. Medicare beneficiaries cannot be charged for completing or filing a claim. Providers may be subject to penalty for violations.

If a beneficiary is enrolled in a Medicare Advantage (MA) Plan, claims should not be submitted to the Medicare FFS Contractor; the beneficiary’s MA Plan is responsible for claims processing. CMS provides a list of MA claims processing contacts on the CMS website.

Medicare Secondary Payer (MSP)

MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage and ensure that Medicare does not pay for services and items that certain other health insurance or coverage is primarily responsible for paying. For more information, reference the “Medicare Secondary Payer for Provider, Physician, and Other Supplier Billing Staff” fact sheet available through the MLN “Catalog of Products” on the CMS website. The Medicare Secondary Payer web page offers information on MSP laws and the various methods employed by CMS to gather data on other insurance that may be primary to Medicare.

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