Basic rules for submitting clean claim - Medicaid

Basic Rules for Completing Blank Non-Institutional 081 Claim Forms

There are some basic rules to follow before completing the claim form.

·  Make sure the Non-Institutional 081 is the right form to use for the claim.
·  Enter all information using black type or a pen using black ink. (The fiscal agent can only process clean claims with black type or ink. Use only black ink on adjusted claims to indicate the item being corrected.)
·  Be sure the information on the form is legible.
·  Enter information within the allotted spaces.
·  Do not use whiteout.
·  Complete the form using the service-specific Coverage and Limitations Handbook as a reference

Before Completing the Form
Before filling out a claim form, answer the following questions:
·  Was the recipient eligible for Medicaid on the date of service?
·  Has the recipient’s eligibility been verified?
·  Was a MediPass or HMO authorization obtained, if applicable?
·  Was the service or item covered by Medicaid?
·  Was the service in the recipient’s plan of care?
·  Was the case manager’s authorization obtained, if applicable?
·  Has a claim been filed, and a response received, for all other insurance held by the recipient?

If all of the above information is not available, review the instructions in this handbook.

If the response to all of the above questions is “yes,” fill out the claim form following the step-by-step instructions for each item on the form.

Recipient’s Name 

Enter the recipient’s last name, first name, and middle initial exactly as it appears on the gold, plastic Medicaid identification (ID) card or other proof of eligibility

Medicaid Identification Number

Enter the recipient’s ten-digit Medicaid ID number. Do not enter the number on the Medicaid ID card. This is a card control number, not the recipient’s Medicaid ID number.

How to bill CMS 1500 form

Block 12. The patient or authorized representative must sign and date this Block unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with §§3047.7-3047.3. If the patient is physically or mentally unable to sign, a representative specified in §3008 may sign on the patient’s behalf.

Block 13. The signature in this Block authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Block 9 and its subdivisions. The patient or his/her authorized representative signs this Block, or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Blocks 14-33 - Provider of Service or Supplier Information

Block 14. Enter the date of current illness, injury, or pregnancy. For chiropractic services, enter the date of the initiation of the course of treatment and enter the X-ray date in Block 19.

Block 15. Leave it blank. Not required by Medicare.

Block 16. Enter dates if patient is employed and unable to work in current occupation. An entry in this field may indicate employment related insurance coverage.

Block 17. Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician.


Block17a – Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. The UPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPI is not available.



Block 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available.
 
Block 18. Complete this Block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.
 
Block 19. Enter the date, the patient was last seen and the NPI of his/her attending physician when an independent physical or occupational therapist or physician providing routine foot care submits claims.
 
Block 20. Complete this Block when billing for diagnostic tests subject to purchase price limitations. Enter the purchase price under charges if the “yes” block is checked.



Block 21. Enter the patient’s diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity.

Block 22. Leave it blank. Not required by Medicare.

Block 23. Enter the Professional Review Organization (PRO) prior authorization number for those procedures requiring PRO prior approval.

Block 24a. Enter the month, day and year for each procedure, service, or supply.

Block 24b. Enter the appropriate place of service code from the list provided in §2010.3. Identify the location where the Block is used or the service is performed. NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.



Block 24c. Medicare providers are not required to complete this Block.

Block 24d. Enter the procedures, services or supplies using the CMS Common Procedure Coding System (HCPCS).


Block 24e. Enter the diagnosis code reference number as shown in Block 21, to relate the date of service and the procedures performed to the primary diagnosis.

Block 24f. Enter the charge for each listed service.

Block 24g. Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, or anesthesia minutes. If only one service is performed, the numeral “1” must be entered.


Block 24h. Leave it blank. Not required by Medicare.

Block 24i. Leave it blank. Not required by Medicare.

Block 24j. Enter the NPI of the performing provider of service/supplier if they are a and member of a group practice.

Block 24k. Enter the first two digits of the NPI in Block 24j. Enter the remaining six digits of the NPI in Block 24k, including the two-digit location identifier.

When several different providers of service or suppliers within a group are billing on the same CMS-1500, show the individual NPI in the corresponding line Block.

Block 25. Enter your provider of service or supplier Federal Tax I.D. (Employer Identification Number) or Social Security Number.

Block 26. Enter the patient’s account number assigned by the provider of service’s or suppliers accounting system. This field is optional to assist you in patient identification. As a service, any account numbers entered here will be returned to you.


Block 27. Check the appropriate block to indicate whether the provider of service or supplier accepts assignment of Medicare benefits.

Block 33. Enter the provider of service/supplier’s billing name, address, zip code, and telephone number.


Enter the NPI, including the 2-digit location identifier, for the performing provider of service/supplier who is not a member of a group practice.

CMS 1500 field and descriptions

Block 8. Check the appropriate box for the patient’s marital status and whether employed or a student.



Block 9. Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in Block 2. Otherwise, enter the word SAME. If no Medigap benefits are assigned, leave blank. This field may be used in the future for supplemental insurance plans.

 Block 9a. Enter the policy and/or group number of the Medigap insured preceded by Medigap

Block 9b. Enter the Medigap insurer’s birth date and sex.


Block 9c. Leave blank if a Medigap *PAYERID is entered in Block 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code, and zip code copied from the Medigap insurer’s Medigap identification card.

For example:

1257 Anywhere Street

Baltimore, Maryland 21204

is shown as “1257 anywhere St MD 21204.”

Block 9d. Enter the nine-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.

Block 10a. Check “YES” or “NO” to indicate whether employment, auto liability, or Thru other accident involvement applies to one or more of the services described Block 10c. in Block 24. Enter the state postal code. Any Block checked “YES,” indicates there may be other insurance primary to Medicare. Identify primary insurance information in Block 11.



Block 10d. Use this Block exclusively for Medicaid (MCD) information. If the patient is entitled to Medicaid, enter the patient’s Medicaid number preceded by “MCD.”

Block 11. THIS BLOCK MUST BE COMPLETED. BY COMPLETING THIS BLOCK, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.



If there is insurance primary to Medicare, enter the insured’s policy or group number and proceed to Blocks 11a - 11c.

Block 11a. Enter the insured’s birth date and sex if different from Block 3.


Block 11b. Enter employer’s name, if applicable. If there is a change in the insured’s insurance status, e.g., retired, enter the retirement date preceded by the word “RETIRED.”

Block 11c. Enter the nine-digit PAYERID number of the primary insurer. If no PAYERID number exists, then enter the complete primary payer’s program or plan name. If the primary payer’s EOB does not contain the claims processing address, record the primary payer’s claims processing address directly on the EOB.

Block 11d. Leave it blank. Not required by Medicare.

CMS 1500 CLAIM FORM FILING INSTRUCTIONS

CMS 1500 CLAIM FORM FILING INSTRUCTIONS

Block 1-13: - Patient and Insured Information.

Block 1. Show the type of health insurance coverage applicable to this claim by checking the appropriate box, e.g., if a Medicare claim is being filed check the Medicare box.



Block la. Enter the patient’s Medicare Health Insurance Claim Number (HICN) whether Medicare is the primary or secondary payer.



Block 2. Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s Medicare card.



Block 3. Enter the patient’s birth date and sex.


Block 4. If there is insurance primary to Medicare, either through the patient’s or spouse’s employment or any other source, list the name of the insured here. When the insured and the patient are the same, enter the word SAME. If Medicare is primary, leave blank.


Block 5. Enter the patient’s mailing address and telephone number. On the first line enter the street address; the second line, the city and state; the third line, the ZIP code and phone number.


Block 6. Check the appropriate box for patient’s relationship to insured when Block 4 is completed.


Block 7. Enter the insurer’s address and telephone number. When the address is the same as the patient’s, enter the word “SAME.”

how to bill CMS1500 - HCFA1500

Instructions in §§2010.1 and 2010.2 (see below) that require the reporting of 8-digit dates
in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit dates in all
other date fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31) are effective for providers of
service and suppliers as of 10/01/98.

Providers of service and suppliers have the option of entering either 6 or 8-digit dates in
items 11b, 14, 16, 18, 19, or 24a. However, if a provider of service or supplier chooses
to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, he or she must enter 8-digit
dates for all these fields. For instance, a provider of service or supplier will not be
permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a 6-digit date for item
24a. The same applies to providers of service and suppliers who choose to submit 6-digit
dates too. Items 12 and 31 are exempt from this requirement.

what is the purpose of claim form

The Form HCFA-1500 answers the needs of many health insurers. It is the basic form prescribed by HCFA for the Medicare program for claims from physicians and suppliers, except for ambulance services. It has also been adopted by the Office of Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) and has received the approval of the American Medical Association (AMA) Council on Medical Services.


Use these instructions for completing this form. The Form HCFA-1500 has space for physicians and suppliers to provide information on other health insurance. Use this information to determine whether the Medicare patient has other coverage which must be billed prior to Medicare payment, or whether there is a Medigap policy under which payments are made to a participating physician or supplier.

What is CMS -1500 or HCFA Claim form-1500

HEALTH INSURANCE CLAIM FORM - HCFA-1500

CMS - 1500 form has 33 Fields. The upper right margin of the claim form should not be used. This area of the claim form is used by the carrier. Any obstructions in this area will hinder timely and accurate processing of claims. The top right margin of the claim form should NOT contain:any type of adhesive-backed labelprinting or headings (including the Medicare carrier address)ink, markers, whiteout, etc.Please print legibly or type all information. Claims may also be computer-prepared.