CMS-1500 Health Insurance Claim Form

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HCFA stands for :
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Health Care Financing Administration
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The HCFA-1500 paper health insurance form was developed in______ by ________________ :
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1975; Health Care Financing Administration (HCFA)
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The HCFA claim form was developed to be used by providers for what purpose?
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Billing Medicare for outpatient services
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HCFA changed its name to what in July of 2001?
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Center for Medicare and Medicaid Services (CMS)
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HCFA-1500 claim form was changed to this in July of 2001 :
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CMS-1500 Universal Claim Form
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For EVERY patient, the patient’s insurance company should be contacted to verify what?
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1) The patient’s eligibility 2) Coverage is in effect 3) Which benefit plan the patient has
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The paper CMS-1500 claim form can be submitted via what means?
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Mailed; or scanned & submitted
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Medicare & Medicaid claim forms may be submitted electronically using the :
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837P standardized encrypted format
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As of October 16, 2003, HIPAA required all claim forms to be submitted electronically with what exception?
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Claims submitted to smaller companies
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Verification of eligibility, coverage, and insurance plan helps the billing specialist with what?
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1) Faster processing of the patient’s services 2) Knowing which expenses the patient is responsible for 3) Assisting in patient education of insurance coverage
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Electronic claims can be submitted in three ways. They are?
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1) Direct data entry 2) Dial-up telephone 3) Computer over the internet
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What is Direct Data Entry?
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Data is electronically transmitted from a provider’s computer system into a health insurer’s computer system.
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What is a Clearinghouse?
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A centralized, independent facility or entity that processes claims electronically to various insurance companies after receiving them from the provider.
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What does a Clearinghouse do with the claims PRIOR to submitting them to the insurance companies?
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They separate the claims by carrier, scrub the claim checking for errors, & submit clean claims to the appropriate insurance company for payment.
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What does a Clearinghouse do with claims with missing or incorrect information?
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Return it to the provider for correction.
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Info found in TOP portion of the CMS-1500?
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Patient related info such as their name, address, date of birth, marital status, gender, insurance info, & possibly employer info if work related.
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Info found in BOTTOM half of the CMS-1500?
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Provider’s service & billing info, incl diagnosis & procedure codes, hospitalization dates, NPI & Tax ID numbers, etc.
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What’s a Signature on File (SOF)?
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Signatures which have been obtained in advance from the provider on the contract with the third party, & from the patient for billing purposes retained in their medical records.
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What does SOF stand for?
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Signature on file
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Where does SOF get entered for the provider?
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Box 31
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Where does SOF get entered for the patient?
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Boxes 12 & 13
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How long must signatures be kept on file AFTER a claim has been submitted?
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72 months
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HOW OFTEN must a provider obtain the patient’s signature to be on file for their record?
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Once a year
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The NPI replaced what two previously used identifiers?
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The PIN & the UPIN
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What is the NPI used for?
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To identify each health care provider & facility for all transactions & with all health plans.
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This 10-digit ID number was required by HIPAA, & assigned by the CMS :
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National Provider Identifier (NPI)
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When does the NPI expire?
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Never. It’s a lifelong number.
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Numbers assigned by IRS to employers for purpose of income tax reporting, & also used on health claims :
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EIN (Employer Identification Number ) or TIN (federal Tax Identification Number)
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What does POS stand for?
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Place of Service code
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What is a POS code used for?
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To identify where services were provided.
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Where are POS codes located?
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In front of CPT book
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What’s an OCR scanner?
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Optical Character Recognition scanner
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NOTHING may be __________ to the CMS-1500 :
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Stapled
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ICR scanners are another method of scanning. ICR stands for :
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Intelligent Character Recognition or Image Copy Recognition
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Scanned CMS-1500 forms must be filled out using :
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Black color, such as black typewriter ink or OCR printer ribbons
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Scanned documents must NEVER be handwritten and all letters must be typed using :
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UPPER CASE letters
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It’s important to align the typewriter or printer so that :
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Words & characters appear in proper fields, & DO NOT touch the lines.
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Don’t use the terms NA or DNA. Do this instead :
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Leave the box blank
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NOT ONLY may you not strike over any errors, you also MAY NOT USE ____________ to cover errors :
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Correction tape or fluid
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Use of these types of pens ARE NOT allowed on CMS-1500 paper claim forms :
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Highlighters or any other color except black
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These types of print, fonts, etc. MAY NOT be used on CMS-1500 claim forms :
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1) Script 2) Italicized font 3) Expanded, compressed, bold, or proportional print
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NOT ALLOWED on CMS-1500 claim forms, UNLESS instructed to do so :
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1) Symbols (such as #, – , /) 2) Period marks 3) Ditto marks 4) Parentheses 5) Commas
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Use this format for the date :
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MM-DD-YYYY
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The ONE exception to usual format used for the date on the CMS-1500 is located where?
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In Box 24A it may be listed as MM-DD-YY so it will fit in spaces provided.
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Make sure all of the X’s are :
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Completely inside their respective boxes.
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Where the following symbols would normally be used, leave a blank space instead :
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1} $ 2} – 3} ()
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UNLESS they appear on the patient’s insurance card, never use these :
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Titles such as Jr. & Sr.
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Express whole dollars by using the following in the \”cents\” column :
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Two zeros
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ALWAYS submit the ORIGINAL CMS-1500 claim form, and NEVER these :
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Photocopies
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If amount received from primary insurance carrier IS NOT in whole dollar amounts, biller would :
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Enter exact amount in Box 29 & adjust balance due in Box 30 before sending claim to secondary or tertiary insurance carrier.
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When dealing with a pregnancy, Box 14 would be filled out using :
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Date of patient’s last menstrual cycle.
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If patient has had the same, or similar, illness in past; in Box 15, the biller would record :
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The date when the patient had the same, or similar, illness the first time.
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For each procedure, service, or supply the patient received in Box 24D, enter the corresponding diagnosis number from:
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Box 21
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If more than one number is needed in Box 24E, then list them in the following manner :
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One after the other with NO PUNCTUATION between them.
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A CLEAN claim has :
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1) No missing data or errors 2) Been filed timely 3) Passed all edits 4) No staples, No highlighted areas, bar code area not deformed 5) No additional work required by biller
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A REJECTED claim :
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1) Cannot be processed due to technical errors, invalid, or missing info, claim submission instructions not being followed 2) Has been submitted to, & rejected by, 3rd party 3) A code is submitted showing reason for rejection 4) Must be corrected, then resubmitted, by Biller
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A DENIED claim :
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1) Services not covered under policy 2) Ineligible service 3) Applied to the deductible 4) No coverage on date of service 5) NOT resubmitted, but forwarded to patient for payment
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A DIRTY claim :
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1) Submitted with errors requiring manual processing 2) 3rd party insurance can either pend, or suspend, the claim 3) Could be rejected 4) Holds up payments 5) Biller may contact 3rd party to attempt to resolve errors & speed payment
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A DINGY claim :
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1) Are the result of the Fiscal Intermediary (FI) 2) They are unable to process it due to system problem 3) Claims are put on hold until necessary changes made to system & claim can be processed.
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An INCOMPLETE claim :
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1) Missing required information. 2) Claim is rejected by the 3rd party 3) Claim is corrected & resubmitted by Biller
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An INVALID claim :
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1) Claim has illogical or incorrect information 2) Claim is rejected by 3rd party 3) Claim is corrected, & resubmitted, by Biller
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Examples of illogical information found on an INVALID claim are things such as :
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1) Provider doesn’t match provider name 2) Patient’s sex doesn’t correlate with procedure 3) Date of birth doesn’t make sense for patient
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A PENDING claim:
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1) 3rd party has suspended this claim for some reason requiring further investigation. 2) Sometimes requires additional info from patient. 3) These claims eventually may be paid or denied. 4) If staff obtains correct info, may be resubmitted for payment
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Claim follow-up is very important because :
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It leads to revenue, which leads to financial stability in the office.

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