question

CMS-1500

answer

the universal claim form

question

When the Health Care Financing Administration (HCFA) became the centers for Medicare & Medicaid Services (CMS)

answer

July 2001

question

HCFA means

answer

Health Care Financing Administration

question

CMS means

answer

Centers for Medicare & Medicaid Services

question

Who requires all physician to use the cms-1500 form when submitting claims for services provided

answer

Medicare

question

Blocks 1 through 13

answer

refers to patient information

question

Blocks 14 through 33

answer

refers to physician information

question

A clearinghouse

answer

Is an entity that receives transmissions from physicians' offices, separates the claims by carriers and performs software edit on each claim to check for errors.

question

Who paid a fee to the clearinghouse for their services

answer

Physicians

question

After the check process is complete by the clearinghouse,the claim is sent to the proper

answer

insurance carrier

question

block 1

answer

medicare #, medicaid #, tricare o champus(sponsor ssn), champva (menber id#, group health plan(ssn or id#), Feca blk lung(ssn), other(ID)

question

block 1a

answer

INSURED ID #

question

block 2

answer

PATENT NAME(Last Name,First Name, Middle Initial)

question

block 3

answer

PATIENT BIRTH DATE SEX

question

block 4

answer

INSURED'S NAME (Last Name, First Name, Middle Initial)

question

block 5

answer

PATIENT ADDRESS

question

block 6

answer

PATIENT RELATION SHIP TO THE INSURED

question

block 7

answer

INSURED'S ADDRESS

question

block 8

answer

PATIENT STATUS

question

block 9 a-d

answer

OTHER INSURED'S NAME a.OTHER INSURED'S POLICY OR GROUP NUMBER b.OTHER INSURED'S DATE OF BIRTH SEX c.EMPLYER'S NAME OR SCHOOL NAME d.INSURANCE PLAN NAME OR PROGRAM NAME

question

block 10

answer

IS PATIENT CONDITION RELATED TO: a.EMPLOIMENT? b.AUTO ACCIDENT? c.OTHER ACCIDENT?

question

block 10d

answer

RESERVED FOR LOCAL USE

question

block 11

answer

INSURED'S POLICY GROUP OR FECA NUMBER

question

block 11a-d

answer

a.INSURED'S DATE OF BIRTH SEX b.EMPLOYER'S NAME OR SCHOOL NAME c.INSURANCE PLAN NAME OR PROGRAM NAME d.IS THERE ANOTHER HEALTH BENEFIT PLAN? if yes return to 9a-d

question

block 12

answer

PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE TO RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESARY TO PROCESS THIS CLAIM.I ALSO REQUEST PAYMENT OF GOVERMMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW SIGNED____________ DATE___________

question

block 13

answer

INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICES DESCRIBED BELOW SIGNED_____________

question

block 14

answer

DATE OF CURRENT ILLNESS (first symptom)OR MM/DD/YY INJURY(accident)OR PREGNANCY(LMP)

question

block 15

answer

IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. GIVE FIRST DATE MM/DD/YY

question

block 16

answer

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION FROM MM/DD/YY TO MM/DD/YY

question

block 17

answer

NAME OFREFERRING PROVIDER OR OTHER SOURCE 17a. 17b.NPI

question

block 18

answer

HOSPITALITALIZATION DATES RELATED TO CURRENT SERVICES FROM MM/DD/YY TO MM/DD/YY

question

block 19

answer

RESRVED FOR LOCAL USE

question

block 20

answer

OUTSIDE LAB? CHARGES

question

block 21

answer

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 1.__._ 3.__._ 2.__._ 4.__._

question

block 22

answer

MEDICAID RESUMISION CODE / ORIGINAL REF. NO.

question

block 23

answer

PRIOR AUTHORIZATION NUMBER

question

block 24 A-J

answer

A.DATE(S) OF SERVICE FROM MM/DD/YY TO MM/DD/YY B.PLACE OF SERVICE C. EMG D.PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circunstances) CPT/HCPCS MODIFIER E.DIAGNOSIS POINTER F. $CHARGES G.DAY OR UMITS H.EPSOT FAMILY PLAN I. J.RENDERING PROVIDER ID#

question

block 25

answer

FEDERAL TAX I.D. NUMBER SSN EIN

question

block 26

answer

PATIENT ACCOUNT NO.

question

block 27

answer

ACCEPT ASSIGMENT?

question

block 28

answer

TOTAL CHARGE

question

block 29

answer

AMOUNT PAID

question

block 30

answer

BALANCE DUE

question

block 31

answer

SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES CREDENTIALS (I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOFF) SIGNED_______ DATE_______

question

block 32

answer

SERVICE FACILITY LOCATION INFORMATION a. b.

question

block 33

answer

BILLING PROVIDER INFO & PH ( ) a. b.

question

Billing Entity

answer

Is the legal business name of the practice.

question

Diagnosis Pointer Number

answer

1 through 4 are preprinted in Block 21 of the CMS-1500 claim, and they are reported in Block24E

question

Medically Unlikely Edits (MUE) Project

answer

To imporve the accuracy of Medicare payments by detecting and denying unlikely Medicare claims on a prepayment basis.

question

Medigap

answer

Plans, which are supplimental palns designed by the Federal Governenment, but sold by private commerical insurnace companies to "cover the gaps in Medicare".

question

National Plan and Provider Enumeration System (NPPES)

answer

Developed by CMS to assign the unique healtcare provider and health plan identifiers and to serve as a database from which to extract data (e.g., health plan verification of provider NPI).

question

Optical Character Reader (OCR)

answer

A device used for optical character recognition.

question

Optical Scanning

answer

Uses a device (scanner) to convert printed or handwritten characters into text that can be viewed by an optical character reader (OCR)

question

Observation Care

answer

A well-defined set of specific, clinically appropriate services, which include ongoing short-term treatmnet, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

question

Direct Admission

answer

Occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department. (ED)

question

Nonphysician Practitioner (NPP)

answer

e.g., nurse practitioner, physician assistant

question

POS

answer

Place of service on CMS-1500 (Appendix II)

UHI Essential CMS-1500 Claim Instructions Chapter 11 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards