Transcript Health Care Claim Preparation & Transmission

Health Care Claim Preparation &
Transmission
Chapter 8
OT 232
Lecture 2
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Completing the CMS-1500 Claim
(cont’d)
– IN 32
• Service Facility Location Information
– Used for information if different than IN33
– Used for providers of diagnostic tests or radiology services
– IN 33
• Provider’s billing info
• Taxonomy codes
– Another form of id that stands for a physician’s
specialty
– Used also if pay can be affected
– Appendix A, page 633
• Awesome summary for CMS-1500, page 262-3
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Completing the HIPAA 837 Claim
• 837 P
– ‘P’ stands for professional services
– Used by physicians
• 837 I
– ‘I’ stands for institutional
– Used by hospitals
• PMP vendors are responsible for
– Keeping the product up-to-date
– Getting certification from HIPAA that their software
accommodates HIPAA-mandated transactions
– Train personnel to use new features
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Completing the HIPAA 837 Claim
(cont’d.)
• PMP’s pull data elements to complete form
– Pieces of information
– 4 types
• R – Required
• RIA – Required if applicable
– Ex. insured differs from patient
• NRUC – Not required unless specified under contract
– Flex boxes
• NR – Not required
– In provider’s records but payer doesn’t need, or already has this info
• 837 is organized differently than the 1500
– More efficient
• There is a hierarchy to how info is sent, so the only
data elements that have to be sent are those that don’t
repeat previous data
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Completing the HIPAA 837 Claim
(cont’d.)
– Provider info
• So if a batch of claims is sent, provider data is sent once and used for
all
• 4 types of providers
– Billing provider
» Sending the claim
– Pay-to provider
» Person or organization that will receive payment for services reported
on the claim
– Rendering provider
» Medical professional who provides the service being reported
– Referring provider
» Physician who refers the patient to another physician for treatment
– One claim could involve all 4
» Dr. A is the referring provider who refers the patient to the rendering
physician Dr. B who works for the pay-to provider, Clinic C, and Clinic C
uses a clearinghouse as a billing provider to transmit its claims. Whew!
– Or one…
» The rendering provider bills for his services and receives payment!
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Completing the HIPAA 837 Claim
(cont’d.)
– Subscriber and patient info
• 1500 uses ‘insured’, 837 uses ‘subscriber’
(Many benefits to electronic form, including more options)
• Claim filing indicator code
– Identifies type of plan
– Valid until a National Payer ID system is in place
– Table 8.5 on page 268
• Relationship of Patient to Subscriber
– Vs. 1500?
– Table 836, page 269
• Other data elements
– Used if another payer is involved
– Patient-specific information
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Completing the HIPAA 837 Claim
(cont’d.)
– Payer info
• Payer obviously knows it’s own info, but helpful for CoB
– Coordination of Benefits
• Remember the order of responsible payers? Primary…
– Secondary, Tertiary, Supplemental
– Claim info
• Info related to a particular claim
• Claim Control Number
– Unique for each claim, NOT the patient’s account number
• Claim Frequency Code
– Aka ‘Claim Submission Reason Code’
» ‘1’ on the initial claim
» ‘7’ on a replacement claim (so they know it’s not a double bill)
» ‘8’ to cancel prior claim
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Completing the HIPAA 837 Claim
(cont’d.)
• Diagnosis Code
– Different from 1500, because can list 8
» (4 on 1500)
– Still must be directly related to treatment
• Claim note
– “flex box”
– Service Line Information
• Diagnosis Code Pointers
– From codes, links to procedures
• Line Item Control Number
– Tracks for services rather than claims
– Service lines are numbered by sender, so easier to match up
when payments are made
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Completing the HIPAA 837 Claim
(cont’d.)
– Claim Attachments
• Separate page of info to support the claim
• Currently no standard form
– Credit/Debit info
• Consent form to bill after adjudication
• Clearinghouses and Claim Transmission
– Check claims
– Transmit claims
• Directly
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Claim Transmission (cont’d.)
• Clearinghouse
– Benefits?
» Accept nonstandard formats and translates them into
standard
» Maps the content of each data element according to the
payer’s instructions
• Cannot create or modify data, ‘fix’ the claim
» Edits the claim and returns to provider for corrections or
missing information
• Direct Data Entry – DDE
– Web based claim form
– Billing providers enters info which goes straight to the payers
• Clean claims vs. Dirty Claims
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