Chapter 07 The Paper Claim CMS-1500 (02-12)

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1

Chapter 07

The Paper Claim CMS-1500 (02-12)

Insurance Handbook for the Medical Office

13th edition

Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved

Background and Submission of CMS-1500 (02-12)

1. Identify the circumstances in which paper claims continue to be used.

2. Discuss the history of the Health Insurance Claim Form (CMS-1500 [02-12]).

3. Define two types of claims submission.4. Explain the difference between clean,

pending, rejected, incomplete, and invalid claims.

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Lesson 7.1


Background and Submission of CMS-1500 (02-12) (cont’d)

5. List the elements typically abstracted from the medical record that are included in a cover letter accompanying an insurance claim.

6. Describe basic guidelines for submitting insurance claims.

7. Explain how the diagnostic field of the CMS-1500 (02-12) claim form would be completed.

8. Explain the difference between PIN, UPIN, and NPI numbers.

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Lesson 7.1


Background and Submission of CMS-1500 (02-12) (cont’d)

9. Discuss the importance of proofreading every paper claim.

10. Describe reasons why claims are rejected.11. Identify claim submission errors, and discuss

the solution to correct the error.12. Identify techniques required for submission of

claims.

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Lesson 7.1


The Paper Claim CMS-1500 (02-12)

Administrative Simplification Compliance Act (ASCA) All claims submitted electronically to

Medicare Some exceptions

• Small providers• Disruption of electricity/communication

connections• Any other health plan• Technical downtime• Reporting special services• Resubmitting a claim• Practice is non-participating• Report patient encounter data 5


History of the Paper Claim CMS-1500

Standard form created in 1958 AMA approved a “universal claim form” in 1975

Originally called Health Insurance Claim Form (HCFA-1500)

Recently called CMS-1500 (08-05) Now called CMS-1500 (02-12)

Revised form made available for optical scanning in 1990

Revised form for NPI inclusion made available in 2005

CMS-1500 (08-05) will no longer be accepted after October 1, 2013

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Types of Submitted Claims

Paper claim Submitted on paper or optically scanned Typed or computer-generated

Electronic claim Submitted via electronic method Digital file not printed on paper

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Claim Status

Clean claim: claim was submitted within the program or policy time limit and contains all necessary information

Physically clean claim: has no staples or highlighted areas, bar code area has not been deformed

Rejected claim: not processed or cannot be processed

Pending claim: held in suspense because of review or other reason

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Medicare Claim Status

Incomplete claim: missing required information

Invalid claim: contains complete, necessary information but is illogical or incorrect

Dirty claim: submitted with errors, requiring manual processing for resolution, or rejected for payment

Deleted claim: canceled, deleted, or voided by a Medicare fiscal intermediary

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Abstracting from Medical Records

Reasons for abstracting from medical records To complete insurance claim forms When sending a letter to justify a health

insurance claim after professional services are rendered

When a patient applies for life, mortgage, or health insurance

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Basic Guidelines for Submitting a Claim

Individual insurance Group insurance Secondary insurance

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Completion of Insurance Claim Forms

Diagnosis Block 21 Primary diagnosis code listed first, followed

by any secondary diagnosis codes• CMS-1500 (02-12) can report up to 12 diagnostic

codes Diagnosis should never be submitted

without supporting documentation in medical record

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Service dates Consecutive dates No charge

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Physicians’ identification numbers State license number Employer identification number (EIN) Social Security number (SSN) National Provider Identifier (NPI) Provider identification number (PIN) Unique physician identification number

(UPIN) Group National Provider Identifier (group

NPI) Durable medical equipment (DME) number Facility provider number Taxonomy code 14



Physician’s signature Insurance biller’s initials Proofread Supporting documentation Office pending file

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Common Reasons Why Claim forms are Delayed or Rejected

Claim submitted to the secondary insurer instead of the primary insurer.

Information missing on patient portion of the claim form.

Patient’s insurance number is incorrect or transposed.

Patient’s name and insured’s name are entered as the same when the patient is a dependent.

Failure to indicate whether patient’s condition is related to employment or an “other” type of accident.

Patient’s signature is missing. Physician’s signature is missing.

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Do’s and Don’ts for Claim Completion

DO: Use original claim forms printed in red ink

DO: Alight printer correctly DO: Keep characters within border of each

field DO: Complete new form for additional

services DO: Enter 6-digit or 8-digit date formats DO: Keep signature within signature block DO: Enter information via computer keyboard

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DON’T: Handwrite information on document

DON’T: Allow characters to touch lines. DON’T: Use specialized characters and

fonts DON’T: Strike over errors

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DON’T: Use highlighter pens or colored in DON’T: Use decimals in Block 21 or dollar

signs in money column. DON’T: Use N/A or DNA when information

not applicable DON’T: Use paper clips, cellophane tape,

stickers, rubber stamps, or staples DON’T: Fold or spindle forms when

mailing

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Practice CMS-1500 (02-12) Submission

13. Demonstrate the ability to complete the CMS-1500 (02-12) claim form accurately for federal, state, and private payer insurance contracts using current basic guidelines.

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Lesson 7.2


Block-By-Block Instructions for Completion of the CMS-1500

(02-12) Carrier Block Block 1: Medicare, Medicaid, TRICARE,

CHAMPVA, Group Health Plan, FECA, Black Lung, Other

Block 1a: Insured’s ID Number Block 2: Patient’s Name Block 3: Patient’s Birth Date, Sex Block 4: Insured’s Name

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(02-12) Block 5: Patient’s Address Block 6: Patient Relationship to Insured Block 7: Insured’s Address Block 8: Reserved for NUCC Use

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(02-12) Block 9: Other Insured’s Name Block 9a: Other Insured’s Policy or

Group Number Block 9b: Reserved for NUCC Use Block 9c: Reserved for NUCC Use Block 9d: Insurance Plan Name or

Program Name

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(02-12) Blocks 10a-10c: Is Patient’s Condition

Related to Block 10d: Claim Codes

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(02-12) Block 11: Insured’s Policy, Group, or

FECA Number Block 11a: Insured’s Date of Birth, Sex Block 11b: Other Claim ID (Designated

by NUCC) Block 11c: Insurance Plan Name or

Program Name Block 11d: Is there another Health

Benefit Plan?

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(02-12) Block 13: Insured’s or Authorized

Person’s Signature Block 14: Date of Current Illness, Injury,

or Pregnancy (LMP) Block 15: Other Date Block 16: Dates Patient Unable to Work

in Current Occupation

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(02-12) Block 17: Name of Referring Provider or

Other Source Block 17a: Other ID Number Block 17b: NPI Block 18: Hospitalization Dates Related

to Current Services Block 19: Additional Claim Information

(Designated by NUCC)

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(02-12) Block 20: Outside Lab Charges Block 21: Diagnosis of Nature of Illness

or Injury Block 22: Resubmission and/or Original

Reference Number Block 23: Prior Authorization Number

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(02-12) Block 24A: Date(s) of Service (Lines 1-6) Block 24B: Place of Service (Lines 1-6) Block 24C: EMG (Lines 1-6) Block 24D: Procedures, Services, or

Supplies (Lines 1-6)

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(02-12) Block 24E: Diagnosis Pointer (Lines 1-6) Block 24F: Charges (Lines 1-6) Block 24G: Days or Units (Lines 1-6) Block 24H: EPSDT/Family Plan (Lines 1-

6)

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(02-12) Block 24I: ID Qualifier (Lines 1-6) Block 24J: Rendering Provider ID #

(Lines 1-6) Instructions and examples of

supplemental information in Item Number 24

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(02-12) Block 25: Federal Tax ID Number Block 26: Patient’s Account No. Block 27: Accept Assignment? Block 28: Total Charge

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(02-12) Block 29: Amount Paid Block 30: Reserved for NUCC Use Block 31: Signature of Physician or

Supplied Including Degrees or Credentials

Block 32: Service Facility Location Information

Block 32a: NPI# Block 32b: Other ID#

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(02-12) Block 33: Billing Provider Info & Ph# Block 33a: NPI# Block 33b: Other ID#

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Insurance Program Templates

Private payer Medicaid Medicare Medicaid/Medigap – a crossover claim Medicare/Medigap – a crossover claim

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Insurance Program Templates

MSP – other insurance primary and Medicare secondary

TRICARE – standard CHAMPVA Workers’ compensation

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Questions?

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Documents

Chapter 07 The Paper Claim CMS-1500 (02-12)