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HIPAA X12 837 Health Care Claim:Professional (837P)

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is a form used to send a claim for physician services to primary and secondary payers.

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CMS-1500

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paper claim for physician services.

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National Uniform Claim Committee

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organization responsible for claim content.

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CMS-1500 (08/05)

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current paper claim approved by the NUCC.

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5010 Version

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new format for EDI transactions.

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Carrier Block

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data entry area in the upper right portion of the CMS-1500.

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Condition Code

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two-digit numeric or alphanumeric code used to report a special condition or unique circumstance.

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Qualifier

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two-digit code for a type of provider identification number other than the NPI.

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Billing Provider

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provider of health services reported on a claim.

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Pay-to-provider

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entity that will receive payment for a claim.

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Rendering Provider

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healthcare professional who provides health services reported on a claim.

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Outside Laboratory

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purchased laboratory services.

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Compliant Claims Require Diagnosis Codes

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A claims that does not report at least one diagnosis code will be denied.

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Primary Diagnosis Codes

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An external cause code cannot be used as a primary diagnosis. Some Z codes are also allowed only as secondary diagnoses.

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Service Line Information

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information about services being reported.

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Correct Use of Section 24

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The top portions of the six service lines are shaded. The shading is not intended to allow the billing of twelve lines of service.

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Dates of Service

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Dates for the same patient that fall in different years must be reported on separate claims.

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Place of Service (POS)

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administrative code indicating where medical services were provided.

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Place of Service

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Payers may authorize different payments for different locations. Higher payments may be made for physician office services, and lower payments for services in ambulatory surgical centers (ASCs) and hospital outpatient departments. When a service is performed in an ASC or outpatient department, check to determine whether it falls under the category of an office service.

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IN 24C

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In the past, this item Number was Type of Service which is no longer used. Type of service codes have been eliminated from the CMS-1500 08/05 claim.

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Unlisted Procedure Code

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When reporting an unlisted procedure code, include a narrative description in IN 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment must be submitted with the claim.

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How Many Pointers?

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According to the NUCC manual, up to four diagnosis pointers can be listed per service line.

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Billing for Capitated Visits

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If the claim is to report an encounter under an MCO capitation contract, a value of zero may be used.

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Medicare NPI Requirements

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Medicare fee-for-service claims must include an NPI for the provider in the primary fields (that is, the billing and rendering fields).

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Address for Service Facility

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Do not use a post office (PO) box in the service facility address.

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administrative code set

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required codes for various data elements

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Administrative Code Sets

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The taxonomy codes are one of the nonmedical or nonclinical administrative code sets maintained by the NUCC. These code sets are business-related. Although the use of an administrative code set is not required by HIPAA, if you choose to report one, it must be on the NUCC list.

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taxonomy code

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administrative code set used to report a physician's specialty

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Follow Payer Guidelines

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Always check with the payer for the claim to ensure correct completion.

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Rejection of Claims Missing Required Elements

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Under HIPAA, failure to transmit required data elements can cause a claim to be rejected by the payer.

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Correct Code Sets

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The correct medical code sets are those valid at the time the healthcare is provided. The correct administrative code sets are those valid at the time the transaction, such as the claim is started.

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Billing Provider Name and Telephone Number

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Note that a billing provider contact name and telephone number are required data elements.

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data element

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smallest unit of information in a HIPAA transaction

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Verifying and Updating Information About Subscribers and Patients

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The HIPAA Eligibility for a Health Plan transaction (the provider's inquiry and the payer's response) is used to verify insurance coverage and eligibility for benefits, as noted in the chapter about patient encounters and billing information. If that transaction turns up new or different information, the changes are correctly posted in the PMP.

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required data element

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information that must be supplied on an electronic claim

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situational data element

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information that must be on a claim in conjunction with certain other data elements

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HIPAA National Plan Identifier

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Under HIPAA, the Department of Health and Human Services must adopt a standard health plan identifier system. Each plan's number will be its National Payer ID. The number is also called the National Health Plan ID.

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responsible party

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other person or entity who will pay a patient's charges

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claim filing indicator code

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administrative code that identifies the type of health plan

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individual relationship code

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administrative code specifying the patient's relationship to the subscriber

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Patient Relationship to Insured

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Patient information forms and electronic medical records should record the relationship of the patient to the insured according to HIPAA categories, so that these data can be included on the HIPAA 837 claim.

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Patient Address

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The patient's address is a required data element, so \"Unknown\" should be entered if the address is not known.

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Assigning a Claim Control Number

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Although sometimes called the patient account number, the claim control number should not be the same as the practice's account number for the patient. It may, however, incorporate the account number. For example, if the account number is A1234, a three-digit number might be added for each claim, beginning with A1234001.

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destination payer

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health plan receiving a HIPAA claim

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Mammography Claims

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The mammography certification number is required when mammography services are rendered by a certified mammography provider.

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claim control number

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unique number assigned to a claim by the sender

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claim frequency code (claim submission reason code)

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administrative code that identifies the claim as original, replacement, or void/cancel action

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Podiatric, Physical Therapy, and Occupational Therapy Claims

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The last-seen date must be reported when (1) a claim involves an independent physical therapist's or occupational therapist's services or a physician's services involving routine foot care and (2) the timing and/or frequency of visits affects payment for services.

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Accident claims

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If the reported services are a result of an accident, the claim allows entries for the date and time of the accident; whether it is an auto accident, an accident caused by another party, an employment-related accident, or another type of accident; and the state or country in which the accident occurred.

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line item control number

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unique number assigned to each service line item reported

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claim attachment

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documentation a provider sends a payer to support a claim

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PHI on Attachments

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A payer should receive only data needed to process the claim in question. If an attachment has PHI related to another patient, those data must be marked over or deleted. Information about other dates of service or conditions not pertinent to the claim should also be crossed through or deleted.

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Specialty Claim Service Line Information

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Claims for various payers require additional data elements. These include Medicare claims, EPSDT/Medicaid claims, and workers' compensation and disability claims.

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clean claim

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claim accepted by a health plan for adjudication

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\"Dropping to Paper\"

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\"Dropping to paper\" describes a situation in which a CMS-1500 paper claim needs to be printed an sent to a payer. Some practices, for instance, have a policy of doing this when a claim has been transmitted electronically twice but receipt has not been acknowledged.

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X12 276/277 Health Care Claim Status Inquiry/Response

answer

The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response transaction is the electronic format practices use to ask payers about the status of claims. It has two parts: an inquiry and a response. It is also called the X12 276/277. The number 276 refers to the inquiry transaction, and 277 refers to the response that the payer returns.

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Functional Acknowledgement 997

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The EDI term for the acknowledgement of a file transmission is the 997. This is not a standard HIPAA transaction but is used with the HIPAA transaction to report that the payer has received it.

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Clearinghouses

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There are many electronic claims and transaction processing firms in the healthcare industry. Most offer services such as claim scrubbing and claim tracking.

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Editing

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Editing software programs called claim scrubbers make sure that all required fields are filled, make sure that only valid codes are used, and perform other checks. Some providers use clearinghouses for editing, and others use claim scrubbers in their billing department before they send claims.

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claim scrubber

answer

software that checks claims to permit error correction

Medical Billing, Coding, and Insurance-Chapter 7

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