Claim Forms

Chapter 10


Claim Forms




Key Terms




Acronyms and Abbreviations


AMA


American Medical Association


ANSI


American National Standards Institute


CMS


Centers for Medicare and Medicaid Services


EDI


Electronic data interchange


EIN


Employer identification number


EMC


Electronic media claim


ER


Emergency room


FL


Form locator


HCPCS


Healthcare Common Procedure Coding System


HIAA


Health Insurance Association of America


HIPAA


Health Insurance Portability and Accountability Act


HIPPS


Health Insurance Prospective Payment System


HRN


Health record number


ICD-10-CM


International Classification of Diseases, 10th Revision, Clinical Modification


ICD-10-PCS


International Classification of Diseases, 10th Revision, Procedure Coding System


MRN


Medical record number


MS-DRG


Medicare Severity-Diagnosis Related Groups


NAICS


North American Industry Classification System Code


NDC


National Drug Code


NPI


National Provider Identifier


NPS


National Provider System


NUBC


National Uniform Billing Committee


OCR


Optical character recognition


PCN


Patient control number


PFS


Patient Financial Services


POA


Present on admission


PPS


Prospective Payment Systems


RA


Remittance advice


SUBC


State Uniform Billing Committees


TIN


Tax identification number


UB-04


Uniform Bill, CMS-1450


UHDDS


Uniform Hospital Discharge Data Set


UHPI


Unique Health Plan Identifier


UPIN


Unique Provider Identification Number



The purpose of this chapter is to provide a basic understanding of claim forms used by hospital facilities to submit charges to payers for reimbursement. A discussion of the purpose of a claim form is followed by a review of manual and electronic claim submission. The provider, payer, and type of service determine claim form usage. A review of claim form variations will describe two forms used for submitting charges to payers: the CMS-1500 and the CMS-1450 (UB-04). Previous chapters have outlined information regarding the claims process, coding diagnoses and procedures, and the relationship between billing and coding. The standard code set currently listed under HIPAA for coding procedures, services, and items is the Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Volume III. In accordance with HIPAA provisions, the ICD-9-CM will be replaced with the International Classification of Diseases, 10th Revision (ICD-10). The compliance date for implementation of ICD-10 was set for October 1, 2013. However, the Department of Health and Human Service (DHHS) has published a final rule that delays the ICD-10 compliance date to October 1, 2014.


Hospital coding and billing professionals will be required to have an understanding of the ICD-9-CM coding system and will need to transition to ICD-10. For this reason, this chapter will provide examples of claim form completion using the ICD-10 coding systems. The chapter illustrates how various elements relate to claim forms. Although hospitals may use both claim forms to submit charges, the CMS-1450 (UB-04) is the primary claim form used for submission of charges for most services, procedures, and items. Therefore, this chapter will provide a brief overview of the CMS-1500, followed by an in-depth discussion on claim form completion requirements for the CMS-1450 (UB-04).



Purpose of Claim Forms


An insurance claim form is a form that is completed by providers for the purpose of submitting charges for medical services and supplies to various third-party payers. Claim forms contain fields for recording data about the provider, insured, date of service, and charges. A provider is an individual or entity that provides medical services and/or supplies to patients. Examples of providers are physician, physician assistant, nurse practitioner, clinic, laboratory, radiology center, hospital, and Ambulatory Surgery Center. Charges are submitted to third-party payers for reimbursement using claim forms. Reimbursement is a term used to describe the payment received from a third-party payer for services rendered by the provider to a patient. Third-party reimbursement for medical services or supplies is determined based on the information reported on the claim form. Claim form information is also used by various organizations and agencies for research, education, and administrative purposes, as discussed in previous chapters.



Claim Form Submission


Claim forms can be submitted to third-party payers manually on paper or by electronic transmission. A manual claim is a paper claim that is typed or computer generated on paper and sent by mail. This is referred to as manual claim submission. An electronic media claim (EMC) is a claim that is transmitted through electronic data interchange (EDI). Electronic data interchange (EDI) is the process of sending data from one computer to another by telephone line or cable. EDI requires data to be in a specific format, and both computers must be set up to send and receive data in the required format.


Today, most claim forms are computer generated and submitted electronically in accordance with payer requirements and Health Insurance Portability and Accountability Act (HIPAA) Title II provisions. Two universal claim forms are used to submit charges to all payers, the CMS-1500 and CMS-1450 (UB-04). Although these claim forms are universal, the guidelines for completion vary by payer. These variations are addressed by setting up a computer template that includes required information by payer type. A template defines all the information required on the claim for the payer, and specific payer edits can also be programmed. The payer-specific knowledge is beyond the scope of this text; however, an overview of general claim form completion requirements is provided. Hospital billing and coding professionals should have knowledge of payer specifications available when submitting claims to various payers. The following review of electronic versus manual claim submission is illustrated in Figure 10-1.




Manual Claim Submission


Manual claim submission involves paper claims that are sent to third-party payers by mail. Historically, all claims were submitted on paper and manually processed by third-party payers. Today, claim forms are designed to be scanned and read using optical character recognition (OCR) technology. Optical scanning is a process whereby the claim form is scanned and the data is transferred into a computer system. Claim forms are outlined in red, which allows the scanner to pick up only data in the fields. Optical scanning replaces the process of having to input data manually from the claim form into a computer system. This technology has improved the efficiency of processing claims for third-party payers. Paper claims are typed or computer generated on paper and sent to various payers primarily by mail. The payer manually inputs or scans the data from the claim form into its computer system. The data on the claim form is then subject to computer edits. When the claim successfully passes through the computer edits, payment determination can be made. An advantage of the paper claim is the ability to review the paper claim before submission; however, there are many disadvantages for providers.



Disadvantages of Paper Claim Submission


A paper claim requires transfer of the data from the claim form to the payer’s computer system. The transfer of data may be accomplished through data entry or scanning. Scanning the claim form does improve the time required for payers to process a claim; however, there are still many disadvantages to the submission of paper claims.








Electronic Claim Submission


In an effort to improve the efficiency of processing claims and reduce associated costs, payers have been moving toward a “paperless” claim process. Electronic claim transmission greatly improves the time it takes for payers to process a claim. Many payers accept paper claims; however, many require claims to be submitted electronically. For example, the Centers for Medicare and Medicaid Services (CMS) requires covered entities to submit claims electronically.


In accordance with HIPAA regulations, standard formats for electronic transactions have been adopted. The adopted standard formats were developed by the American National Standards Institute (ANSI). The standard transaction format for the CMS-1500 is the ANSI X12 837 and the format for the CMS-1450 (UB-04) is ANSI X12 837I. The standard transaction formats contain elements found on the CMS-1500 and CMS-1450 (UB-04) paper claims. The current standard format, Version 5010, was adopted and implemented. The compliance date for all HIPAA-covered entities to transition to Version 5010 was January 1, 2012. Details regarding Version 5010 can be viewed on the CMS Web site at www.cms.gov/ICD10/11a_Version_5010.asp#TopOfPage.


The electronic claim process can be accomplished in two ways: direct transmission to the payer or transmission through a clearinghouse. Direct transmission is when a provider transmits claims directly to various payers. Providers can also submit claims through a clearinghouse that reformats claim data to meet payer requirements and then transmits claim data to various payers.




Transmission Through a Clearinghouse


A clearinghouse is an organization that reformats claim data received from providers to meet compatibility specifications for submission to various payers. After the data on the claim is reformatted and edited, the claim is electronically transmitted by the clearinghouse to the appropriate payer.


The electronic claim submission process for a hospital is illustrated in Figure 10-2. Functions required to complete the process are performed by the hospital’s Patient Financial Services (PFS) Department. Data required for claim submission is recorded on the patient’s computerized account during the patient visit. The hospital’s computer system performs edits to identify issues with the claim data. Any issues identified during the edit process can be resolved before transmission. Claims are then prepared and transmitted to the payer directly or through a clearinghouse. The clearinghouse may also conduct edits. After the claim has satisfied the payer’s edit, payment determination is made. A remittance advice (RA) is forwarded to the hospital that explains payment determination. Remittance advices can also be transmitted electronically by various payers.



The major disadvantage to electronic claim submission is the need for various versions of software or a clearinghouse. Another disadvantage is that claims requiring attachments cannot be submitted electronically. Despite these disadvantages, many providers elect to transmit claims electronically because the advantages are greater than the disadvantages.



Advantages of Electronic Claim Submission


Electronic transmission of claims improves the payer’s processing time and therefore helps to improve cash flow. The advantages of electronic claims involve tracking, proof of receipt, processing time, reimbursement, and compliance.








Claim Form Variations


Two claim forms are universally accepted by payers today: the CMS-1500 and the CMS-1450 (UB-04). The CMS-1500 is used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement. The CMS-1450 (UB-04) is used by institutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement. It is necessary to complete these claim forms in accordance with payer guidelines and specifications. Claim form completion specifications vary by payer. Hospital billing professionals are required to gain knowledge regarding various payer specifications for claim form completion. The category of service generally dictates which claim form is used. Claim form variations for outpatient, inpatient, and non-patient services are outlined in Figure 10-3.





BOX 10-1   Test Your Knowledge
PURPOSE OF CLAIM FORMS; CLAIM FORM SUBMISSION; CLAIM FORM VARIATIONS


True/False






Matching


Select the answer option that matches the descriptions below.





11. ____ Claim form used by institutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement.


12. ____ The process of sending data from one computer to another by telephone line or cable.


13. ____ A group of claims that is prepared and transmitted together.


14. ____ A claim that is transmitted through electronic data interchange (EDI).


15. ____ Claim form used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.


16. ____ An individual or entity, such as a doctor or hospital, that provides medical services and/or supplies to patients.


17. ____ A process whereby the claim form is scanned and data on the claim are transferred into a computer system.


18. ____ Provisions outlined under this legislation require the electronic transmission of most health care transactions.


19. ____ An organization that reformats claim data received from providers to meet compatibility specifications for submission to various payers.


20. ____ A claim that is typed or computer generated on paper and sent by mail.



CMS-1500 Claim Form Overview


The CMS-1500 is the universal claim form accepted by most payers for submission of charges for physician and outpatient services. The Health Insurance Association of America (HIAA) and the American Medical Association (AMA) developed the CMS-1500, formerly known as the HCFA-1500, in 1958. The claim form was developed in an attempt to standardize the form used to submit charges to payers. In 1992, the claim form was printed in red ink and adopted by the CMS for use in submission of claims for Medicare patients. Other payers followed suit, and the claim form is now accepted by most payers. Completion requirements and specifications vary by payer to accommodate computer systems and various health insurance plans. This section will focus on the CMS-1450 (UB-04), since most hospital services are submitted using this claim form.



Claim Form Data


The CMS-1500 claim form consists of 33 blocks used to record the following four sections of information.







CMS-1450 (UB-04) Claim Form Overview


The CMS-1450 (UB-04) is also referred to as the UB-04 because it is the universal bill accepted by payers. It is the required form outlined under HIPAA. The CMS-1450 (UB-04) is used to submit facility charges for outpatient, inpatient, and non-patient services. This claim form was developed and is maintained by the National Uniform Billing Committee (NUBC). The National Uniform Billing Committee (NUBC) was formed by the American Hospital Association in 1975 to develop a single billing form and a standard data set that could be used nationally by institutional providers. The original standard form was the UB-82, which was adopted for use in 1982. The form underwent revisions again in 1992, and the UB-92 was adopted. The UB-92 was replaced by the CMS-1450 (UB-04) effective May 2007. Today, the role of the NUBC is to maintain the integrity of the CMS-1450 (UB-04) data set. The data set contains information required for each field on the claim form. State Uniform Billing Committees (SUBC) are responsible for the oversight of state-specific CMS-1450 (UB-04) billing requirements.



Claim Form Data


The CMS-1450 (UB-04) consists of 81 data fields that are referred to as form locators (FL). The billing requirements for each field and the revenue codes are revised on an ongoing basis by the NUBC, SUBC, and CMS. The CMS-1450 (UB-04) can be viewed in four sections, in which information about the patient, facility, charges, and physicians involved in the patient’s care is recorded, as illustrated in (Figure 10-4).





Section II: Charge Information (FL 42 to 49)


This section requires detailed information about the charges submitted, including revenue code and description, Healthcare Common Procedure Coding System (HCPCS) code and rates, National Drug Code (NDC), service date, service units, total charges, and non-covered charges. Charge capture data gathered during the patient visit are used to print a detailed itemized statement and to complete FL 42 to 49. Charges are captured during the patient visit and posted through the Charge Description Master (CDM), which is also referred to as the chargemaster. Each item in the chargemaster is associated with the appropriate revenue code category, HCPCS code, and other charge information. The detailed itemized statement lists each charge individually. Completion of FL 42 to 49 requires all charges captured during the patient stay to be grouped in revenue code categories. Each revenue code category is listed on one line in FL 42 to 49 along with other associated data, such as HCPCS code, charge, and units.





CMS-1450 (UB-04) Instructions


The CMS-1450 (UB-04) is a summary of the hospital visit and charges incurred. Information used to complete the claim form is entered into the patient’s account on the computer. Required claim data for each field are pulled from the patient’s account and the hospital data file. Information about charges for services provided is outlined on the detailed itemized statement, which may be attached to manual claims. Payers who require electronic claims submission may request a detailed itemized statement after initial review of the CMS-1450 (UB-04) claim data. Completion requirements and specifications for the CMS-1450 (UB-04) vary by payer; therefore, it is critical to obtain payer specifications to ensure compliance with payer guidelines. Detailed information regarding the claim form and instructions for completion can be viewed on the CMS Web site at www.cms.gov/ElectronicBillingEDITrans/15_1450.asp. General instructions for each form locator (FL) are outlined below in four sections to provide a basic understanding of the data required.



Section I: Facility, Patient, Admission, Discharge, Occurrence, and Value Information (FL 1 to 41)


This section is used to provide information about the facility, when the patient was admitted and discharged, the patient’s name and address, and other information about the hospital visit, as illustrated in Figure 10-5. An overview of data required for each form locator (FL) is outlined below.







FL 3b: Medical/Health Record Number (MRN)

FL 3b is used to record the medical record number. The medical record number (MRN) is a number assigned by the facility to a patient’s medical record. The MRN is used to identify, track, and retrieve the medical record for a patient. The medical record number is not the same as the patient control number (PCN). Remember, the PCN is assigned by the facility to a specific claim. The MRN is also referred to as the health record number (HRN). This field is required by Medicare, and most other payers require completion of this field.




FL 4: Type of Bill

The four-digit type of bill number is recorded in this field to provide information about the facility bill type. The first digit is zero. The second digit describes the facility type. The third digit indicates the type of care. The fourth digit is designed to let the payer know the expected frequency of the bills that will be submitted. Examples of type of bill code options include 0111 (Hospital inpatient-admit through discharge claim) and 0113 (Hospital outpatient-admit through discharge claim) as illustrated in Concept Review Box 10-7. A detailed listing of FL 4, type of bill, three-digit options and common fourth-digit frequency code options is outlined in Appendix B.


Mar 24, 2017 | Posted by in NURSING | Comments Off on Claim Forms
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