Monday, April 20, 2015

Medicare Billing: 837P and Form CMS-1500

What are the 837P and Form CMS-1500?
837P: The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. Review the chart below “ANSI ASC X12N 837P” for more information about this claim format.

Form CMS-1500:The Form CMS-1500 is the standard paper claim form that health care professionals and suppliers use to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.
In order to align the CMS-1500 with some of the changes in the electronic format, the previous 08/05 version was revised to the 02/12 version. Visit the National Uniform Claim Committee (NUCC) website
for information on the revision process. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (02/12) and the form is referred to throughout this fact sheet as the CMS-1500.

In addition to billing Medicare, the 837P and Form CMS-1500 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.


The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional)
Version 5010A1 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
P = Professional version of the 837 electronic format Version
5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers.

          Implementation and Companion Guides for Electronic Transactions
Health care professionals or suppliers billing electronic claims must comply with the ASC X12N implementation guide. The “837P Health Care Claim: Professional” implementation guide is available for purchase and provides instructions on the content and format requirements for each of the standards’ requirements. ASC X12N implementation guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards’ requirements. These documents are written for use by all health benefit payers, not specifically for Medicare.

Implementation Guides, including Version 5010 Consolidated Guides, can also be purchased from the
Washington Publishing Company on the Internet. CMS publishes a companion guide to supplement the implementation guide and provide further instruction specific to Medicare. The “5010A1 Part B 837 Companion Guide” is located on the CMS website and provides specific 837P claim loop and segment references. MACs also publish their own companion documents, which provide additional information specific to that contractor’s business. To locate a MAC’s companion guide, visit that contractor’s website.
Please note that the implementation guides and companion guides are technical documents and health care professionals or suppliers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims
Health care professionals and suppliers play a vital role in protecting the integrity of the Medicare Program by submitting accurate claims, maintaining current knowledge of Medicare billing policies, and ensuring all documentation required to support the medical need for the service rendered is submitted when requested by the MAC.

In addition to correct claims completion, Medicare payment requires that an item or service:
• Meets a benefit category;
• Is not specifically excluded from coverage; and
• Is reasonable and necessary.
In general  fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist.

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. It is a crime to defraud the Federal government and its programs. Punishment may involve imprisonment, significant fines, or both under a number of laws including the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the Criminal Health Care Fraud Statute.

When Does Medicare Accept a Paper Form CMS-1500?

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

ASCA Exceptions: Before submitting a hard copy claim on the Form CMS-1500, health care professionals and suppliers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, health care professionals and suppliers that have fewer than 10 Full-Time
Equivalent (FTE) employees and bill a MAC are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If a health care professional or supplier meets an exception, there is no need to submit a waiver request.

Waiver Requests: 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 a health care professional’s or supplier’s staff prevents use of a computer for electronic submission of claims. Health care professionals and suppliers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their MAC.

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