1 / 10

Health Care Claim Preparation & Transmission

Health Care Claim Preparation & Transmission. Chapter 8 OT 232 Lecture 2. 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

evonne
Download Presentation

Health Care Claim Preparation & Transmission

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Health Care Claim Preparation & Transmission Chapter 8 OT 232 Lecture 2 OT 232 Ch 8 lecture 1

  2. 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 OT 232 Ch 8 lecture 1

  3. 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 OT 232 Ch 8 lecture 1

  4. 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 OT 232 Ch 8 lecture 1

  5. 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! OT 232 Ch 8 lecture 1

  6. 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 OT 232 Ch 8 lecture 1

  7. 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 OT 232 Ch 8 lecture 1

  8. 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 OT 232 Ch 8 lecture 1

  9. 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 OT 232 Ch 8 lecture 1

  10. 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 OT 232 Ch 8 lecture 1

More Related