Transcript 8.6 Completing the HIPAA 837 Claim

CHAPTER
8
Health Care Claim
Preparation and
Transmission
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-2
Learning Outcomes
When you finish this chapter, you will be able to:
8.1
8.2
8.3
8.4
8.5
Distinguish between the electronic claim transaction
and the paper claim form.
Discuss the content of the patient information
section of the CMS-1500 claim.
Compare billing provider, pay-to provider, rendering
provider, and referring provider.
Discuss the content of the physician or supplier
information section of the CMS-1500 claim.
Compare required and situational (required if
applicable) data elements on the HIPAA 837 claim.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-3
Learning Outcomes (Continued)
When you finish this chapter, you will be able to:
8.6
8.7
8.8
8.9
Identify the five sections of the HIPAA 837 claim
transaction and discuss the data elements that
complete it.
Explain how claim attachments and credit-debit
transactions are handled.
Define a clean claim.
Identify the three major methods of electronic claim
transmission.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-4
Key Terms
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•
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administrative code set
billing provider
carrier block
claim attachment
claim control number
claim filing indicator code
claim frequency code
(claim submission
reason code)
• claim scrubber
• clean claim
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CMS-1500
CMS-1500 (08/05)
condition code
data element
destination payer
HIPAA X12 837 Health
Care Claim or Equivalent
Encounter Information
• HIPAA X12 276/277
Health Care Status
Inquiry/Response
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-5
Key Terms (Continued)
• individual relationship
code
• legacy number
• line item control number
• National Uniform Claim
Committee (NUCC)
• other ID number
• outside laboratory
• pay-to provider
• place of service (POS)
code
• qualifier
•
•
•
•
•
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rendering provider
required data element
responsible party
service line information
situational data element
taxonomy code
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Introduction to Health Care Claims
8-6
• The HIPAA-mandated electronic transaction for
claims is the HIPAA X12 837 Health Care
Claim or Equivalent Encounter Information—
used to send a claim to primary and secondary
payers
– The electronic HIPAA claim is based on the CMS1500, which is a paper claim form
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.1 Introduction to Health Care Claims
(Continued)
8-7
• National Uniform Claim Committee (NUCC)–
organization responsible for claim content
– CMS-1500 (08/05)—current paper claim approved by
the NUCC
• Legacy number—provider’s identification
number issued prior to the National Provider
Identification system
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.2 Completing the CMS-1500 Claim:
Patient Information Section
8-8
• The CMS-1500 claim has a carrier block and
thirty-three Item Numbers (INs)
• Carrier block—data entry area in the upper
right of the CMS-1500
• Condition code—two-digit numeric or
alphanumeric codes used to report a special
condition or unique circumstance
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.2 Completing the CMS-1500 Claim:
Patient Information Section (Continued)
8-9
• The upper portion of the CMS-1500 claim form
(Item Numbers 1-13):
– Lists demographic information about the patient and
specific information about the patient’s insurance
coverage
– Information is entered based on the patient
information form, insurance card, and payer
verification data
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8-10
8.3 Types of Providers
• It may be necessary to identify four different
types of provider:
1. Pay-to provider—person or organization that will be
paid for services on a HIPAA claim
2. Rendering provider—term used to identify an
alternative physician or professional who provides
the procedure on a claim
3. Billing provider—person or organization sending a
HIPAA claim
4. Referring provider
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Completing the CMS-1500 Claim:
Physician/Supplier Information Section
8-11
• This part identifies the health care provider,
describes the services performed, and gives the
payer additional information to process the claim
• Other ID number—additional provider
identification number
• Qualifier—two-digit code for a type of provider
identification number other than the NPI
• Outside laboratory—purchased laboratory
services
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Completing the CMS-1500 Claim:
8-12
Physician/Supplier Information Section (Cont.)
• Service line information—information about
services being reported
• Place of service (POS) code—administrative
code indicating where medical services were
provided
• Taxonomy code—administrative code set used
to report a physician’s specialty
• Administrative code set—required codes for
various data elements
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.4 Completing the CMS-1500 Claim:
8-13
Physician/Supplier Information Section (Cont.)
• The lower portion of the CMS-1500 claim form
(Item Numbers 14-33):
– Contains information about the provider or supplier
and the patient’s condition, including the diagnoses,
procedures, and charges
– Information is entered based on the encounter form
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8-14
8.5 The HIPAA 837 Claim
• Data element—smallest unit of information in a
HIPAA transaction
– Example: a patient’s name
– Required data element—information that must be
supplied on an electronic claim
– Situational data element—information that must be
on a claim in conjunction with certain other data
elements
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.6 Completing the HIPAA 837 Claim
8-15
• The five sections of the HIPAA 837 claim
transaction include:
–
–
–
–
–
Provider information
Subscriber information
Payer information
Claim information
Service line information
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.6 Completing the HIPAA 837 Claim
(Continued)
8-16
• Responsible party—other person or entity who
will pay a patient’s charges
• Claim filing indicator code—administrative
code that identifies the type of health plan
• Individual relationship code—administrative
code specifying the patient’s relationship to the
subscriber
• Destination payer—health plan receiving a
HIPAA claim
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.6 Completing the HIPAA 837 Claim
(Continued)
8-17
• Claim control number—unique number
assigned to a claim by the sender
• Claim frequency code (or claim submission
reason code)—administrative code that
identifies the claim as original, replacement, or
void/cancel action
• Line item control number—unique number
assigned to each service line item reported
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.7 Handling Claim Attachments and
Credit-Debit Transactions
8-18
• Claim attachment—additional data in printed or
electronic format sent to support a claim
– Examples include lab results, specialty consultation
notes, and discharge notes
• Patient credit-debit transactions are carefully
processed and recorded by the practice
– The amount charged is reported to the patient once
billed
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.8 Checking Claims Before Transmission 8-19
• Claims are carefully reviewed before
transmission
• Clean claim—claim accepted by a health plan
for adjudication
– Properly completed and contains all the necessary
information
• HIPAA X12 276/277 Health Care Claim Status
Inquiry/Response—electronic format used to
ask payers about claims
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
8.9 Clearinghouses and Claim
Transmission
8-20
• Practices handle the transmission of electronic
claims with three major methods:
1. In the direct transmission approach, providers and
payers exchange transactions directly
2. The majority of providers use clearinghouses to
send and receive data in correct EDI format
3. Some payers offer online direct data entry (DDE) to
providers, which involves using an Internet-based
service into which employees key the standard data
elements
• Claim scrubber—software that checks claims to
permit error correction
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.