quay week 3

Student instructions

1. If you have questions about this activity, please contact your instructor for assistance.

2. You will review the chart of Liu Huang to complete this activity. Your instructor has provided you with a link to the CMS 1500 (BS) activity. Click on 2: Launch EHR to review the patient chart and begin this activity.

3. Refer to the patient chart and any suggested resources to complete this activity.

4. Document your answers directly on this activity document as you complete the activity. When you are finished, you will save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS).

The activity

The CMS-1500 form, developed by The Centers for Medicare and Medicaid (CMS), is the standard form used to submit claims for reimbursement from government insurance plans like Medicare. Although originally created just for government insurance plans, the form has become the standard form used by all insurance carriers. The proper submission of this form is crucial for providers to receive timely payment for their services. (Medicare Learning Network, 2011)

Errors when completing the CMS 1500 Form

Whether the CMS 1500 form is filed on paper or electronically through software, claim submission errors will occur. The goal is to eliminate those errors or, at the very least, reduce the number of errors to improve and accelerate the claims process.

The Centers for Medicare & Medicaid Services (CMS) describes an unprocessable claim as "Any claim with incomplete or missing, required information or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally." (Medicare Learning Network, 2011)

The edit process was developed by the Centers for Medicare and Medicaid Services (CMS) to reduce costs and administrative waste. This editing process returns paper and electronic claims to the provider as unprocessable. No appeal rights are afforded to these claims, or portion of these claims, because no “initial determination” can be made, therefore rendering the claim unprocessable. The billing staff should make corrections and must resubmit claims.

Some of the more common reasons for a claim to be unprocessable are:

· Missing required data.

· Ineligible required data on a paper form.

· Invalid numbers (insurance, DOB, etc.).

· Procedure and modifier are inconsistent.

· Missing, incomplete or invalid charge(s).

· Place of service is incorrect.

Completing the CMS 1500 Form

To ensure immediate and accurate payment for services, these requirements should be met:

· Ensure that all relevant fields are properly filled in the manner it should be filled.

· Use appropriate codes to fill patient medical details. Details can be taken from the personal data of the patient that was collected during examination.

· It is important to accurately enter fields like date of birth of patient, the health insurance number etc.

· The names of both the insured as well as the patient should be entered correctly. Often it happens that the insured person is not the patient and in such cases, it is important to enter the name of the insured in the box earmarked for the same.

· Section 11 of the CMS 1500 claim form is mandatory and must be filled, as it determines whether the patient is covered under Medicare or not.

· Lastly, ensure that the form is signed by the patient along with the date. Once this is done, it can be submitted as per hospital rules and regulations.

(Medicare Learning Network, 2011)

Questions

The Central Clinic is fine-tuning its electronic claim submissions. You have been asked to audit the electronic claim form of the EHR and identify any missing fields in the form’s electronic format that could cause the claim to be rejected. Review the paper claim form found in the Resources section of this activity. Compare each field on the paper form to the electronic version in the Claims and Ledger sections of the EHR found under the Account tab. For each of the fields listed, which are numbered corresponding to their number on the paper form, indicate whether the field is completely present, partially present/not clear or not present on the electronic claim. Please note that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields.

1. Insurance type & Insured’s I.D. Number

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

2. Patient’s name

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

3. Patient Birth Date

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

4. Insured’s name

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

5. Patient’s address

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

6. Patient’s relationship to insured

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

7. Insured’s address

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

8. Patient status

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

9. Other insured’s name

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

10. Is the patient’s condition related to (employment/auto accident/other accident)

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

11. Insured’s policy group or FECA number, date of birth, employer, plan name, benefit plan name (if applicable)

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

12. Authorization release

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

13. Insured’s signature

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

14. Date of condition

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

15. First date of condition

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

16. Dates patient unable to work in current occupation

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

17. Name of referring physician, I.D. number of referring physician

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

18. Hospitalization dates related to current services

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

19. N/A (Reserved for local use). Skip to next question.

20. Outside lab charges?

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

21. Diagnosis or nature of illness or injury

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

22. Medicaid resubmission code (if applicable)

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

23. Prior authorization number (if applicable)

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

24. Procedural codes for services rendered and related diagnostic code pointer

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

25. Federal tax I.D. number

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

26. Patient’s account number

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

27. Accept assignment? Yes or No

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

For 28-30, see the Ledger Tab. Keep in mind that you are auditing the availability of the fields themselves, and not the patient data, or lack thereof, entered in the fields.

28. Total charges

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

29. Amount paid

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

30. Balance due

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

31. Signature of physician to be reimbursed

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

32. Name and address of facility where the services were rendered

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

33. Physicians, suppliers billing name, address, zip code, and phone number

a. Completely present on electronic claim

b. Partially present or not clear on electronic claim

c. Not present on electronic claim

34. List the items that were not completely present or were missing from the electronic claim.

35. Of the missing or incomplete items, which do you think would be most likely to cause this electronic claim to be rejected?

36. Do you think paper submission or electronic submission of the CMS 1500 billing form would result in less errors? Explain your answer.

Submit your work

Document your answers directly on this activity document as you complete the activity. When you are finished, save this activity document to your device and upload this activity document with your answers to your Learning Management System (LMS). If you have any questions about submitting your work to your LMS, please contact your instructor.

References

Empire Blue Cross Blue Shield. (2003, June). Empire Blue Cross Blue Shield. Retrieved from Empire Blue Cross Blue Shield Claim Form: https://www.empireblue.com/provider/noapplication/f5/s1/t2/pw_b157015.pdf? Medicare Learning Network. (2011). CMS 1500 At a Glance. Washington D.C.: CMS.