Friday, May 22, 2015

Medicare Billing: 837I and Form CMS-1450

What are the 837I and Form CMS-1450?

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 Administrative Contractors (MACs) when a paper claim is 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.

Implementation and Companion Guides for Electronic Transactions

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. The documents are written for use by all health benefit payers, not specifically for Medicare. Implementation guides, including Version 5010 consolidated guides, can be purchased at the ASC X12 store or from the Washington Publishing Company on the Internet.

CMS publishes a companion guide to supplement the implementation guide to provide further instruction specific to Medicare. The “5010A2 - Part A 837 Companion Guide” is located on the CMS website and provides  specific 837I electronic 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. Implementation guides and companion guides are technical documents, and providers may require assistance from software vendors or clearinghouses to interpret and implement the information within the guides.

Submitting Accurate Claims

Providers 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 coverage and payment is contingent upon a determination 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 include 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 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 MAC 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 MAC.

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