Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. The Health Insurance Claim Form Chapter 20

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc.

The Health Insurance Claim Form

Chapter 20


Introduction

Medical insurance means different things to different people:

Mounds of paperwork Mass of confusion Constant change Lifesaving help for high medical expenses


This chapter will examine: Differences between paper claims and electronic

claims Guidelines for completing the CMS-1500 form Completing each of the blocks of the CMS-1500

form Differences between clean and dirty claims Methods of preventing claim rejection Checking claim status


Universal Claim Form CMS-1500 Claim Form Revised 08/05 Used for most claims submitted to insurance

companies


Types of Claims Hard copies

– Physically printed and mailed to insurance companies Electronic claims

– Submitted via electronic media


Methods of Electronic Claims Submissions

Direct billing– Transmitted directly to the insurance carrier

Clearinghouses– Submits insurance claims to the carrier for the providers


Advantages and Disadvantagesof Electronic Billing


Electronic Claims Processing Reduces the time required for reimbursement Can reduce error rates by 1% to 2% Shortens payment cycle


National Provider Identifier All allied health providers of service will be

assigned one provider number. Uniform, national number replaces the many

numbers used by the various providers. SSN, EIN, and TIN must still be used for tax and

income reporting purposes.


Data Gathering Guidelines Photocopy the insurance ID card, back and front. Obtain demographic information about the

patient. Obtain information on both policies if the patient

has more than one. Get information about the insured if he or she is

different from the patient. Obtain needed signatures for permission to bill

and accept payment directly from the insurance company.


Verification of Eligibility and Benefits Call the insurance company to verify benefits. Obtain a general overview of covered items.


Assignment of Insurance Benefits


CMS-1500 Health Insurance Claim Form Standardized form used by most insurance

carriers. Recently revised slightly to include the NPI. The 08/05 version must be in use by all providers

after April 1, 2007. Contains three sections

– Address of carrier– Patient information– Provider information, including diagnosis and procedure

codes


Carrier Block


Blocks 1 to 8


Blocks 9 to 13


Blocks 14 to 23


Blocks 24 to 33


Denied or Rejected Claims

Always follow up on denied or rejected claims to discover if a simple fix is appropriate.


Checking Claim Status Periodically check to see what claims have not

been paid. Contact the carrier to determine the issue with

the claim. Provide more information as needed. Continue follow-up efforts.


Audit Trails Used to verify that information was submitted

correctly Provide a record Locate sources of errors

Documents

Copyright © 2007 by Saunders, Inc., an imprint of Elsevier Inc. The Health Insurance Claim Form Chapter 20