Using the CMS 1500 claim form: a tutorial on filling out and sending the claim form to insurance.
No matter where you work in a medical office, you'll have to be familiar with the CMS 1500 form.
It's the standard form used to bill all medical claims to commercial and government insurance companies.
Medical coders and billers use this form on a daily basis. They have to know exactly what each box means and how to fill the form out accurately. There are over thirty-three boxes, each of which has to be completed with the correct information.
If any one of the boxes contains incorrect information or is filled out the wrong way, the entire claim may be denied, or processed incorrectly.
Use this tutorial to learn how to avoid these situations!
Because it would be too difficult and time consuming to discuss each single element of the CMS 1500 claim form, we won't do that here.
It's much easier to think of the form as containing sections of data, each of which combine together to tell the insurance company:
There's also a section for charges.
The insurance company reviews the form, determines the patient's benefits, and pay the negotiated rates per their agreement with each individual provider.
At the very top of the claim form, on the right hand side, is a section for the patient's insurance claims address. This is the address to which you are supposed to send all claims for that particular insurance company.
Underneath the address is a complicated set of numbered and lettered boxes. These boxes are divided into two main sections:
They contain all the information necessary for the insurance company to process the claim.
The top half of the CMS 1500 claim form, Patient and Insured Information, identifies the patient, the insurance subscriber, and the insurance policy.
The first set of information is the patient data, including:
Because the patient isn't always the insurance subscriber, but instead a child, spouse, or other dependent on the policy, this is a necessary relationship to include. It's so that the insurance company can determine whether or not the dependent is covered under the insurance policy.
The next section is the subscriber's information, including:
All of this data also helps the insurance company determine the patient's benefits, as well as the type of policy that the insured person holds.
After these boxes, there's a large section to include the insurance ID numbers and policy identifying information. This is necessary because it also helps identify the patient, determine whether or not he or she is eligible for benefits, and what type of benefits are available.
Also included here is a section where you can indicate whether or not the medical visit was due to an accident, which may be covered under worker's compensation or vehicle insurance.
And last but not least, there's a section where you can include additional insurance information.
Sometimes patients have more than one type of insurance coverage. In this case it's necessary to include this information to make sure that the claim is paid correctly by the primary insurance.
Unsure how to determine the primary and secondary payer? Click for more information on determining coordination of benefits.
The second half of the CMS 1500 claim form is the section labeled Physician and Supplier Information. Unlike the previous section, this one doesn't contain any pertinent patient, subscriber, or insurance plan information.
Instead, this section contains all the information from the patient visit, including:
The top portion of this section contains an area to include any necessary referring provider information, including referral authorization number, dates of patient illness or injury, and outside lab charges.
Underneath this section is one of the most important sections of the CMS 1500 claim form: the diagnosis code pointers.
The claim form only allows enough room for four diagnoses. Each has to be listed in order, starting from the primary diagnosis, and each is numbered (for reference).
Directly underneath the diagnosis codes are the procedure codes. They're listed individually, per date of service, and each relates to a specific diagnosis code or codes.
Directly to the right of the codes are spaces for medical coding modifiers, and farther to the right, charges.
Finally, on the very right hand side of the form, is a section for the provider's individual NPI and taxonomy code. This tells the insurance who performed the service, and what type of provider they were.
At the very bottom of the form is where the provider's office includes its billing information. Depending on how the claim is billed, this section may include the group NPI numbers or individual provider NPI number, as well as individual provider signature.
Once you've filled out the CMS 1500 claim form, simply send it to the insurance company listed on the top of the page.
If your claim is more than one page, then send all the pages together at the same time. You can also send multiple claims for different patients to the same insurance at the same time.
Hopefully this tutorial helped to show you that each part of the CMS 1500 claim form contains a vital piece of information, each of which is needed to get the claim paid!
Click for more information on the CMS 1500 claim form, including changes since the implementation of HIPAA.
Master the CMS 1500 form with this guide.
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