Chapter 21 the Health Insurance Claim Form

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Assignment of Benefits

The transfer of the patient's legal right to collect benefits for medical expenses to the provider of those services; the patient authorizes sending of the payment directly to the provider.

Audit

A process done before claims submission to examine claims for accuracy and completeness. It can be performed manually, or it can be done electronically with computer billing software.

Audit Trail

The path left by a transaction when it has been completed; often referred to when tracking medical services used by patients or researching claims.

Clean Claim

An insurance claim form that has been completed correctly (no errors or omissions); they can be processed and paid promptly if they meet the restrictions on covered services and blocks.

Clearinghouse

A centralized facility to which insurance claims are transmitted. They seperate, check, and redistribute claims electronically to various insurance carriers and may offer additional services to the physician.

Direct Billing

A method of electronic claims submission in which computer software allows a provider to submit an insurance claim directly to an insurance carrier for payment.

Dirty Claim

A claim form that contain errors or omissions; they must be corrected and resubmitted to an insurance carrier to obtain reimbursement.

Electronic Claim

A claim subitted to an insurance processing facility through a computerized medium, such as direct data entry, direct wire, dial-in telephone digital fax, or personal computer download or upload.

EDI

Electronic Data Interchange is the transfer of data back and forth between two or more entities using an electronic medium.

Electronic Signature

A scanned signature or other such mark that is accepted as proof of approval of and/or responsibility for the content of an electronic document.

EIN

Employer Identification Number is the number used by the Internal Revenue Service to identify a business or individual functioning as a business entity for income tax reporting.

ICR

Intellignet character recognition is the electronic scanning of printed blocks as images and the use of special software to recognize these images (or characters) as ASCII text for upload into a computer database.

NPI

National Provider Identifier is a lifetime number consisting of 10 digits that Medicare uses to replace the Provider Identification Number (PIN) and the Unique Physician Indentification Number (UPIN).

Paper Claim

A hard copy of an insurance claim, which is completed and sent by surface mail.

Rejected Claims

Claims returned unpaid to the provider for clarification of any questions; they must be corrected before submission.

UPIN

Unique Provider Indentification Number is a number assigned by fiscal intermediaries to identify providers on claims for services.

Universal Claim Form

The form used to submit all government-sponsored claims; also known as the CMS-1500 form. It was developed by the agency that became the Centers for Medicare and Medicaid Services (CMS) and approved by the American Medical Association (AMA)

CMS-1500 form

It is the Universal claim form and that it has two portions to the form, top half has the patient information and the botton has the physician/supplier information. Was developed in 1988.

CMS-1500 (08-05) Form

(basic guidlines for submitting a claim) should always be used. It is accepted by all private insurance carriers as well as Medi-Cal, Medicare, TRICARE and Workers' Compensation.
A claim form should be completed and submitted whenever services are charged, even if the patient states the service will not be covered. An official rejection from the insurance carrier is the best answer to present to the patient in most situations.

HCFA

Health Care Financing Administration (determines Medicare payment system); Created in 1977, under DHHS, take care of insurance for 67 million; insure quality assurance through the Medicaid and Medicare programs. They basically do whatever they want with our tax dollars to insure the people to worthless to go get a job.

CMS

Centers for Medicare and Medicaid Services was renamed by HCFA in 2001.

Transaction

When money goes into, or out of, your account. Can include deposits, withdrawals, payments, fees, ATM transactions or transfers.

HIPAA

is the development of "transaction and codes sets" for all insurance-related information sent electrontically, including claim form submissions, claims status requests, and remittance (payment) processing.

ASC X12N

Chartered by ANSI in 1979 to develop electronic data interchange (EDI) standards.
Responsible for insurance/ claims/ reimbursement standards.
HIPAA requires the use of a number of X12N standards

3 sections

Section 1: Carrier Block, Section 2: Patient/Insured Section, Section 3: Physician/Supplier Section

Section 1: Carrier Block

Contains the address of the insurance carrier and is located at the top of the form

Section 2: Patient/Insured Section

Contains information about the patient and the insured (if other than the patient); includes boxes 1 throuh 13.

Block 1: Type of Insurance

this block indicates the type of insurance the patient has. Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

Block 1a: Insured's ID Number

The ID number identifies the patient to the payer. The primary insurance ID number is used in this block The patient may not be the insured, but the ID number should identify the patient as covered for benefits.

Block 2: Patient's Name

The name of the patient is the person who recieves treatment or supplies. The patient's last name should be entered first, then first name, and middle initial (e.g., Doe, John A.)

Block 3: Patient's Birth date and Sex

The patient's birth date and sex help identify the patient and differeniate patients with similar names.

Block 4: Insured's Name

This block identifies the person who owns the policy. .

Block 5: Patient's Address

The patient's address and telephone number are entered in this block. Use the patient's permanent address; do not use a temporary or school address.

Block 6: Patient's Relationship to Insured

"Self" indicates the patient is the insured.
"Spouse" indicates the patient is married to the insured.
"Child" indicates the patient is the inusred's minor dependent.
"Other" could mean that the patient is an employee; that workers' compensation is the insurer; or that the patient is a ward or other dependent as defined by the insured's plan.

Block 7: Insured's Address

The insured's address and telephone number are entered in this block. Use the insured's permanent address, which may be different from the patient's address in block 5.

Block 8: Patient Status

These boxes are important for determining liability and coordinating benefits.
Employment: Check this box if the patient is employed, whether full-time or part-time.
Full- or part- time student: Check as appropriate, depending on the school's definition of full-time and part-time status. Generally, a student taking 6 or fewer credit hours is considered part-time.

Section 3: Patient/Inusred Section

This section contains information about the patient and insured person, and contains Boxes 9 through 13.

Block 9: Other Insured's Name

The other insured's name idicates that another insurance exists that may cover the patient. This block is completed only if there is a secondary insurance policy and that policy is to be billed.

Block 9a: Other Insured's Policy Group

The other insured's group number or policy number identifies coverage for the insured as indicated in block 9. (Block 1a in Procedure 21-2 presents guidelines for ID numbers for Medicare, Medicaid, group health plans, FECA/Black Lung, and other carriers.)

Block 9b: Other Insured's Date of Birth and Sex

The other insured's birth date and gender help identify the birth date and gender of the insured as indicated in block 9.

Block 9c: Employer's or School Name

This block identifies the other insured's employer or school as indicated in block 9.

Block 9d: Insurance Plan or Program Name

The insurance plan name or program name identifies the name of the plan or program of the other insured as indicated in block 9.

Block 10a-c: Is Patient's Condition Related to

This block indicates whether the patient's conditon is the result of an employment injury or illness, auto accident, or other accident.

Block 10d: Reserved for Local Use

Some third-party payers require that this boxed be used. Refere to the instructions from that applicable third-party payer.

Block 11: Insured's Policy Group, or FECA Number

This block is completed for the primary insurance claim. The policy, group, or Federal Employees Compensation Act (FECA) number is the alphanumeric identifier for the insurance plan coverage. Workers' compenstation claims use the carrier's alphanumeric identifier. A FECA number is a 9 digit alphanumeric identifier assigined to a patient who claims to have a work-related condition under the FECA.

Block 11a: Insured's Date of Birth, Sex

This block is completed for the primary insurance claim. This information applies to the person indentified in block 1a.

Block 11b: Insured's Employer's or School Name

This block is completed for the primary insurance claim. This is the name of the employer or school attended by the insured as indicated in block 1a.

Block 11c: Insurance Plan or Program Name

This block is completed for the primary insurance claim. The insurance plan or program name is the name of the plan or program of the insured in block 1 (Carrier Block).

Block 11d: There another Health Benefit Plan

This block indicates whether the patient has insurance coverage other than that indicated in block 1. If there is secondary coverage, check YES. If not or no claim is submitted using the secondary coverage, check NO.

Block 12: Patient's or Authorized Person's Signature

The signature is an authorization for the release of any medical or other information necessary to process or adjudicate the claim. The signature of the patient or the patient's representative is required. In the case of computer-generated claims, an authorization form permitting the release information that has the patient's signature must be kept in the patient's record; the words "Signature on File: may be entered in this file.

Block 13: Insured or Authorized Person's Signature

The insured's or authrized person's signature indicates that a signature is on file authorizing payment of medical benefits.

Physician/Supplier Section

third section contains boxes 14 to 23 and details physician or supplier information.

Block 14: Date of Current Illness, Injury, or Pregnancy

The date should be the date whent the current illness or condition began, the date the injury happened or, with pregnancy, the date of the last monthly period (LMP).

Block 15: Same or Similar illness

If the patient has had the same or similar illness or condition, enter the onset data of the earlier conditon. This block is used by the insurance carrier to determine whether any pre-existing condition existed that might affect reimbursement.

Block 16: Dates Patient unable to Work in Current Occupation

This section refers to the time span durign which the patient was unable to work in his or her current occupation. Enter the first date the patient was unable to work in the current occupation and the date when teh patient was able to return to work. If the patient has not returned to work, leave the "End Date" field blank. This block is used to help determine an employee's long- or short-term disability payments.

Block 17: Name of Referring Provider or Other Source

The name of the referring provider, ordering provider, or other source who referred or ordered the service or procedure on the claim is entered in this block.
Referring physician- A physician who requests an item or service for the beneficiary for which payement may be made.
Ordering physician- A physician or, when appropriate, a nonphysician practitioner who orders nonphysician services for the patient.

Block 17a: Other ID

It was used previously for a personal identification number (PIN), which became obsolete in 2008.

Block 17b: NPI Number

HIPAA established the National Provider Identification (NPI). In the past, each insurance carrier, including government programs, assigned an identifier to each provider service. All allied healthcare providers of serivce now are assigned an NPI, which the provider can use regardless of the insurance carrier being billed. The NPI replaces Medicare's Unique Provider Identification Number (UPIN) and almost all other federal, state, and private insurance carriers' Provider Identification Numbers (PINs). The NPI does not replace the Social Security number (SSN), employer identification number (EIN), or federal tax identification number (TIN) used by a provider of service. The SSN, EIN, and TIN are used for income and tax purposes and for reporting to the Internal Revenue Service.

Block 18: HDRCS

The hospitalization dates related to current services refer to an inpatient hospital stay. Enter the admission and discharge dates associated with service on the claim.

Block 19: Reserved for Local Use

Some payers ask for certain identifiers in this field. Refer to the instructions of the applicable third-party payer. Medicare has specific uses for this block if services were rendered by certain provider or the certain services, drugs, or diagnostic tests. See Medicare Claims Processing Manual for instructions.

Block 20: Outside Lab and Charges

This field refers to diagnostic laboratory services that have been rendered by an independent or seperate provider in block 32. A "yes" check indicates that an entity other than the provider billing for the service performed the diagnostic test, and the provider in block 33 paid the laboratory test directly. A "no" check indicates "no purchased tests are included on the claim." When "yes" is annoted, the amount the provider was charged by the diagnostic laboratory is entered, and block 32 should be completed with the name and address of the diagnostic laboratory or other entity.

Block 21: Diagnosis or Nature of illness or injury

The diagnostis or nature of illness or injury refers to the signs, symptoms, complaint, or condition of the patient relating to the services on the claim. The diagnosis or ICD-9-CM code or codes should be entered in this block. Enter one code for each of the four fields in the block. No more than four diagnosis codes should be used on one claim form.

Block 22: Medicaid Resubmission

The code and original reference number assigned by the insurance payer should be entered in this block if a Medicaid claim previously submitted has not been reimbured and also to resubmit the claim to Medicaid, or its intermediary, for payement.

Block 23: Prior Authorization Number

The prior authorization number referes to the payer-assigned number authorizing the service(s), procedure(s), and/or referral.

Physician/Supplier Section

the third section contains boxes 24 to 33 and details physician or supplier information

Block 24A: Date(s) of Service

Lines 1-6 are Date(s) of service indicate the actual month, day, and year the service was provided.

Block 24B: Place of Service

Lines 1-6 in this block identifies where the services were provided. Enter the 2 digit place of service (POS) code (Table 21-2) in this block.

Block 24C: EMG

Lines 1-6 in this field is used to indicate whether the services provided involved an emergency. Enter a Y in this block if the services were provided in emergency circumstances. Medicare providers are not required to complete this item.

Block 24D: Procedures, Services, or Supplies

Lines 1-6 are the procedures, services, or supplies refer to a list of identifying codes for reporting medical services and procedures.

Block 24E: Diagnosis Pointer

Lines 1-6 are where to enter the diagnosis code field, or reference, number as shown in block 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services have been performed, enter the primary field number for each service, either a 1, a 2, a 3, or a 4. This is a required filed. If a situation arises in which tow or more diagnoses are required for a procedure code (e.g., Pap smears), the provider may refereance only one of the diagnoses in block 21.

Block 24F: $ Charges

lines 1-6 are $ charges refers to the total billed amount for each service lines. If a series of services were performed on any one line, multiply the number of days or units (field 24G) by the charge for one procedure or service and enter the total amount for all days or units.

Block 24G: Days or Units

lines 1-6 are days or units refer to the number of days that correspond to the dates entered in 24A, or units as defined in the CPT or HCPCS coding manuals. This field is most commonly used for multiple visits, units of supplies, or anesthesia minutes.

Block 24H: EPSDT/Family Plan

lines 1-6 for the EPSDT/Family Plan identifies certain services covered under state plans. (EPSDT is the acronym for "early and periodic screening, diagnosis, and treatment.") Refer to the approrpiate insurance payer's guidelines (typically Medicaid or the Medicaid intermediary) for instructions on completing this block. Leave blank for Medicare, TRICARE, CHAMPVA, group health plans, FECA/Black Lung, and most other types of insurance.

Block 24I: Renderding Provider ID Qualifier

lines 1-6 of the rendering provider is the person or company that rendered or supervised the care.

Block 24J: Rendering Provider ID Number

lines 1-6 of the enter the NPI number of the individual performing or rendering the service in the shaded portion of block 24J. If no NPI number exists, enter the provider identification number (PIN) and the appropriate 2 character qualifier.

Block 25: Federal Tax ID Number

The federal tax identification number (TIN) refers to the unique identifier assigned by the Internal Revenue Service.

Block 26: Patient's Account Number

The patient's account number which is assigned by the provider of service, is entered in block 26. The account number assists the provider in location the patient's financial and record.

Block 27: Accept Assignment

The "accept assignment" indicates that the provider agrees to accept assignment under the terms of the Medicare program and some other insurance payers. Check this block if the provider participates in the insurance payer's program; that is the provider is a participating physician and agrees to abide by the terms of the agreement to accept assignment and writer off the difference between the original charge and the allowable amount set by the insurance carrier.

Block 28: Total Charge

The total charge is the amount billed on this claim form for all services rendered. Add the charges reported in block 24F for all the lines of services on the claim form.

Block 29: Amount Paid

The amount paid is the payment received from the patient or other payers.

Block 30: Balance Due

The amount left after the patient has paid a co-pay or co-insurance is entered in this block.

Block 31: Signature of Physician or Supplier

The signature is the provider's verification that the claim is correct.

Block 32: SFLI

The name, address, city, state, and ZIP code identify the site where service were rendered.

Block 32a: NIP Number

Enter the NPI number of the service facility.

Block 32b

If the service facility does not have an NPI number, enter the payer-assigned identifier of the facility and the qualifer number.

Block 33: BPI and PH

The address and phone number of the provider who wants to be paid on this claim are entered in this block.

Block 33a: NPI Number

The NPI number of the billing provider is entered in this block.

Block 32b: Other ID number

The non-NPI number ofthe billing provider refers to the payer-assigned unique identifier of the professional. The 2 character qualifier of the non-NPI number is also entered in this block.

SOF

signature on file - indicates a physical signed form is on file with the biller

PAR

participating provider

2 main reason for denial

1. Technical errors and 2. Insurance Policy coverage issues.

2 common reason for rejected

1. a procedure list on the claim is not a covered service and 2. the insurance payer considers the procedure a pre-existing condition.

ALT

Assumption of Liability before treatment(s).

tracer

an instrument used to make tracings

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