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8.1 HIPAA X12 837 Care Claim or Equivalent Encounter Information

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Used to send a claim to primary and secondary payers (based on the paper claim form CMS-1500)

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8.2 CMS-1500

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paper claim for physician services

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8.1 NUCC - National Uniform Claim Committee

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led by the AMA; determines the content of both HIPAA 837 and CMS-1500 claim content

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8.2 CMS-1500 (08/05)

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current paper claim approved by the NUCC

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8.1 NPI

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HIPAA-mandated National Provider Identifier

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8.1 Legacy Numbers

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provider's identification number issued prior to the National Provider Identification system

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8.2 CMS-1500 Patient Information Section

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claim has a carrier block and (33) thirty-three Item Numers (INs)

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8.2 CMS1500-Carrier Block

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in upper right of the CMS-1500; allows for 4-line address for the payer

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8.2 Patient Information

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has a carrier block & 33 Item Numbers (IN's)

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8.2 CMS 1500 Patient Info. Section INs 1-13

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refers to patient demographic info and specific info about their insurance

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8.2 CMS 1500 Patient Info. Section INs 14-33

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contain information about the provider and the patient's condition, including the diagnosis, procedures, and charges.

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8.2 Condition Code

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two-digit numberic or alphanumeric codes used to report a special condtion or unique circumstance; i.e. AA=Abortion performed due to Rape AB=Abortion performed due to Incest

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8.3 2-digit Qualifier BG

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a condition code indicating a specified condition will follow

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FECA

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Federal Employees' Compensation Act;

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FECA number

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a 9-digit alphanumeric identifier assigned to a patient who is an amployee of the federal government claiming work-related conditions(s) under the Federal Employees' Compensation Act.

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8.3 How many types of Providers are there?

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Four different types of Providers 1. Pay-to-provider 2. Rendering Provider 3. Billing provider 4. Referring provider

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8.3 Pay-to-provider

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Physician practice - the person or organization that will be paid for services on a HIPAA claim

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8.3 Rendering Provider

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doctor who provides care for the patient & is a member of the physician practice that gets the payment.

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8.3 Billing Provider

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Billing service or clearinghouse to transmit claims.... a separate billing

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8.3 Referring or Ordering Physician

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another physician who may have sent the patient.

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8.4 CMS 1500 - Second half of the CMS 1500 Claim

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Physician / Supplier Information Section; identify the health care provider, describe the services performed and give the payer additional information to process the claim.

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8.4 Providers have 2 types of ID numbers

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1. Non-NPI ID = other ID # or Legacy Number 2. NPI

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8.4 Non-NPI ID or Legacy Number

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refers to the payer-assigned unique identifier of the physician

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8.4 Qualifier

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two-digit alphanumeric code for a type of provider identification number other than the NPI; followed by the number itself

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8.4 NPI Number

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National Provider Identifier - Under HIPAA, unique ten-digit identifier assigned to each provider by the national provider System.

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8.4 Qualifiers for Other ID Number

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alphanumeric numbers that give additional provider information

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8.4 CMS 1500 -In IN 17a two parts of the other ID number are entered

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first part: Qualifier = 2 digit code indicating what the number represents second part: the number itself i.e. 1B ABC1234567890

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8.4 CMS 1500 - IN 17b the NPI Number is entered

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NPI 0123456789

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8.7 Outside Laboratory (claim attachment)

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purchased laboratory services; services performed at an outside independent laboratory

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8.8 Compliant Claims Require ICD-9-CM Codes

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A claim that does not report at least one ICD-9-CM code will be denied

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Primary Diagnosis Codes

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An E code (external cause of injury or poisoning)cannot be used as a primary diagnosis. Some V codes (factors that influence health status not due to illness or injury) are also allowed only as secondary diagnoses.

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8.4 CMS 1500 -Service Line Information

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information about services being reported; procedures- performed for the patient. Seen in section 24 of CMS 1500

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8.4 CMS 1500 -INs 24A thru 24J have

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Top portions of the six service lines are shaded. The shading is not intended to allow the billing of twelve lines of service.... only 6

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CLIA number

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Clinical Laboratory Improvement Amendments number;

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8.6 Claim Frequency Code / Medicaid Resubmission Number

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7 = Replacement of prior claim 8 = Void/ cancel of prior claim

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8.4 Prior Authorization Number

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refers to the payer assigned number authorizing the service(s); Allows for SIX procedures to be listed

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8.4 Place of service codes

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2-digit codes used for section 24 in CMS 1500

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8.4 Diagnosis Pointer

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refers to the line number from IN21 that provides the link between diagnosis and treatment ( up to four may be listed per service line)

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Total billed charges for each service

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Should be entered withouth $ signs, decimals or cmmas

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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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8.4 Item DAYS or UNITS

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Enter # of days or units... most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume

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8.8 Medicare NPI Requirements

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Medicare fee0for-service claims must include an NPI in the primary fields... in the billing, pay-to, and rendering fields

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8.8 Amount Paid Does NOT include:

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payment for noncovered charges

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8.8 Signatures

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No stamped signatures allowed; only signatures or electronic

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8.8 Address for Service Facility

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No PO numbers

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8.1 Administrative Code Set

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required codes for various data elements; maintained by the NUCC. They are business-related. If Administrative Code Set is reported, it must be on the NUCC list.

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8.4 Taxonomy Code

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Administrative code set used to report a physician's specialty; a 10-digit number that stands for a physican's medical specialty.

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8.5 HIPAA 837 P

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HIPAA transaction for electronic claims generated by physicians; The hospital version of the claim is called 847 I (I = Institution)

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8.5 NR Data Elements

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Not Required Item Numbers from the CMS-1500 that are not needed on the HIPAA 837 Claim. - Patient's/Insured's telephone number - Patient's employement or student status - Marital status - school name - balance due

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8.8 Under HIPAA a claim will be rejected if:

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It does not contain - required elements - correct Code Sets - Billing Provider name and Telephone Number

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8.5 HIPAA 837 claim requires data on these types of Providers

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- Billing Provider - Pay-to-Provider - Rendering Provider - Referring Provider

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8.4 Data Element

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smallest unit of information in a HIPAA transaction i.e. patient's first name, middle name or initial and last name. Organized differently for electronic transmission.

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8.6 Five major sections of HIPAA 837 claim transaction

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1. provider information 2. Subscriber & patient information 3. payer information 4. claim Details and information 5. Services / Service line information

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8.5 Required Data Element

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information that must be supplied on a electronic claim

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8.5 Situational Data Element

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information that must be on a claim in conjuction with certain other data elements. i.e. if unsured differes from patient, the insured's name must be entered

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8.6 Subscriber Information

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Name and address of the Responsible Party - person other than the patient who has financial responsibility for the bill

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8.6 Claim Filing Indicator code

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An administrative code used to identify the type of health plan... i.e. PPO, HMO etc..

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8.6 Individual Relationship Code

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adminstrative code specifying the patient's relationship to the subscriber (2-digit code)

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8.6 HIPAA 837 -Claim Control Number

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Unique number assigned to a claim by the sender; appears on payment from payers

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8.6 Destination payer

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Health Plan receiving a HIPAA claim. Information about the Payer (health plan) to whom the claim is going to be sent.

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8.6 Claim Information Section

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Reports information related to the particular Claim; details of visit i.e. due to accident etc..

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8.6 HIPAA 837 -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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8.6 HIPAA 837 -Claim Frequency Code also indicates whether claim is:

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1 Original Claim 7 Replacement of prior Claim 8 Void / Cancel of Prior Claim

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8.4 Service Line Information / Line Item Control Number

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Diagnosis Code pointer A unique number assigned to each service line item reported by the sender

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Accident Claims

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the claim allows entries for the date & time of the accident; what kind of accident; if it's caused by employment or other party; and state or country where it occured

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8-7 Claim Attachment

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additional data in printed or electronic format a provider sends to a payer to support a claim. i.e. lab results; consultation notes and discharge notes

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8.7 Payment by Credit or Debit

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practice takes payment info and charges to card at a later date after TOS.

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8.8 Clean Claim

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claim accepted by a health plan (payers) for adjudication (examining claim and determining benefits)

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8.8 Adjudication

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process of examining claim and determining benefits

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8.8 Claim Errors

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- missing or incomplete service facility name, address or info. - missing Medicare assignment indicator or benefits assignment indicator - invalid provider Identifier - Missing birth date - Missing payer name or identifier - Incomplete other payer info. - Invalid procedure codes

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8.8 Data Entry Tips

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No prefixes for names (Mr. Mrs. Dr.) No dashes, hyphens, commas etc.. No dashes, spaces in phone numbers

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8.9 Clearinghouses and Claim Transmission

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Outside Electronic claims and transaction processing firms in the health care industry. Offer services like claim scrubbing and claim tracking.

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8.9 EMC

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Electronic Media Claims, or Electronic Claims

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Functional Acknowledgment 997

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Acknowledgment of a file transmission is the 997. Not a standard HIPAA transaction

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8.9 Methods of Transmitting Claims

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1. Direct Claims Transmission (providers & payers exchange transactions directly w/out using a clearinghouse) 2. Clearinghouse - majority of providers use clearinghouses to send & receive data in correct EDI format. 3. Direct Data Entry (DDE) to providers

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8.9 DDE- Direct Data Entry

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Internet based service into which employees key standartd data elements; they are loaded directly into the health plans' computers

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8.4CMS 1500 - Lower portion of claim form, IN 14-33

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Contains info. about provider / supplier Patient's condition; diagnosis, procedures charges

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8.6 HIPAA 837 - Line Item Control Number

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Unique number assigned to each service line item reported

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8.8 HIPAA Z12 276/ 277 Health Care Claim Status

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electronic format used to ask payers about claims

Medical Billing Chapter 8

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