Assignment 3 - Medical Insurance Billing and Coding


Question Description

Steps to complete Assignment

Please complete CMS 1500 InsuranceCLAIMform for the Medicare patients, using the Informationfrom the Insurance card and insurance verification form. In order to complete the assignment you will to download and read the Medicare files thoroughly to find all the information you will need. Then fill in each form completely with the appropriate information that is in each file for reimbursement. remember empty cells or wrong information will cause the claim to be rejected.

Please complete only the information which is provided in the verification form and Insurance card. Do not worry about the information which is not available.

Refer to the video for filling CMS 1500

Unformatted Attachment Preview

CARRIER 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA PICA MEDICARE MEDICAID (Medicare #) (Medicaid #) TRICARE CHAMPUS (Sponsor’s SSN) GROUP HEALTH PLAN (SSN or ID) CHAMPVA (Member ID#) 3. PATIENT’S BIRTH DATE MM DD YY 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) OTHER 1a. INSURED’S I.D. NUMBER FECA BLK LUNG (SSN) (ID) 4. INSURED’S NAME (Last Name, First Name, Middle le e IInitial) SEX M 5. PATIENT’S ADDRESS (No., Street) F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Child Spouse STATE STAT CITY Married Other TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) C A M P LE ZIP CODE 7. INSURED’S ADDRESS (No., Street) Other 8. PATIENT STATUS Single (For Program in Item 1) ( ) Employed Full-Time Student Part-Time Student ( ) 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) RED’S DATE OF BIRTH RE a. INSURED’S MM DD YY b. OTHER INSURED’S DATE OF BIRTH MM DD YY b. AUTO ACCIDENT? SEX PLACE (State) c. EMPLOYER’S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE RANCE PLAN NAME OR PROGRAM NAME NO YES d. INSURANCE PLAN NAME OR PROGRAM NAME PLAN? d. IS THERE ANOTHER HEALTH BENEFIT P 10d. RESERVED FOR LOCAL USE E YES READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other ther information necessary ne to process this claim. I also request payment of government benefits either to myself or to the partyy who ho accepts assignment below. SIGNED 14. DATE OF CURRENT: MM DD YY NO return to and complete item 9 a-d. If yes s, re PERSON’S SIGNATURE I authorize 13. INSURED’S OR AUTHORIZED P payment of medical benefits tto the undersigned physician or supplier for services described below. serv DATE ATE TE ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) F b. EMPLOYER’S NA NAME OR SCHOOL NAME NO YES F M SEX M NO YES FORM PATIENT AND INSURED INFORMATION 1. SIGNED 15. IF PATIENT NT T HAS HAD SAME OR SIMILAR ILLNESS. 16. D PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DATES PATIE DD YY DD YY MM MM DD YY GIVE FIRST IRST RST DATE MM TO FRO FROM 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 18. HOSP MM DD YY MM DD YY FROM TO F 17a. 17b. 7 NPI 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? 2 YES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Relate ate Items 1, 2, 3 or 4 to Item 24E by Line) 1. $ CHARGES NO 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 2. 24. A. MM 1 2 3 4 YY B. C. C PLACE OF SERVICE EMG 4. SUPPLIES RES, SERVICES, OR SUP D. PROCEDURES, (Explain Unusual usual Circumstanc Circumstances) MODIFIER CPT/HCPCS MODI MOD E. DIAGNOSIS POINTER F. $ CHARGES H. G. I. J. RENDERING PROVIDER ID. # EPSDT ID. Family Plan QUAL. DAYS OR UNITS NPI NPI NPI NPI S 5 DATE(S) OF SERVICE From To DD YY MM DD NPI 6 25. FEDERAL AL TAX I.D. NUMBER SSN EIN S 31. SIGNATURE OF PHYSICIAN OR SUPPLIER YSIC INCLUDING DEGREES EES OR CREDENTIALS (I certify that the statements on the reverse me apply to this bill and are made a part thereof.) SIGNED DATE NPI 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? (For govt. claims, see back) YES NO 32. SERVICE FACILITY LOCATION INFORMATION a. NUCC Instruction Manual available at: NPI b. PLEASE PRINT OR TYPE 28. TOTAL CHARGE $ 29. AMOUNT PAID 33. BILLING PROVIDER INFO & PH # a. 30. BALANCE DUE $ NPI $ ( ) b. APPROVED OMB-0938-0999 FORM CMS-1500 (08-05) PHYSICIAN OR SUPPLIER INFORMATION 23. PRIOR AUTHORIZATION NUMBER BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42 CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge, ed edi and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are e based upon the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but ealth insura insuran makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor provided in those nsor sor should be pro items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11. BLACK LUNG AND FECA CLAIMS The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions ctions tions regarding regarding required proce procedure and diagnosis coding systems. LE SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK ACK LUNG) I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally onally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise wise expressly permitted permitted by Medicare or CHAMPUS regulations. For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered supervision ed under the physician’s immediate mmediate personal supe super by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, physician’s e, 3) tthey must be of kinds commonly only furnished in ph offices, and 4) the services of nonphysicians must be included on the physician’s bills. For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active Uniformed civilian employee tive ve duty membe member of the Unifor med Services or a civ of the United States Government or a contract employee of the United States Government, either Black-Lung claims, her civilian ivilian or military (refer to 5 USC C 5536). For B Bl I further certify that the services performed were for a Black Lung-related disorder. No Part B Medicare benefits may be paid unless this form is received as required by existing isting sting law and regulations (42 CFR 424.32). 424.32). NOTICE: Any one who misrepresents or falsifies essential information to receive payment ment ent from Federal funds requested by this form form may upon conviction be subject to fine and imprisonment under applicable Federal laws. A M P NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK L LUNG INFORMATION LU (PRIVACY ACT STATEMENT) We are authorized by CMS, CHAMPUS and OWCP to ask you for information Medicare, CHAMPUS, FECA, and Black Lung ation needed in the administration of the Medicar Medicare programs. Authority to collect information is in section 205(a), 1862, 1872 2 and nd 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and 44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 613; E.O. 9397. C 8101 et seq; and 30 USC 901 et seq; 38 USC 6 The information we obtain to complete claims under these programs eligibility. It is also used to decide if the services ms is used to identify you and to determine your el and supplies you received are covered by these programs and d to insure that proper payment is mad made. The information may also be given to other providers of services, boards, health plans, and other organizations or Federal vices, ces, carriers, intermediaries, medical review boar agencies, for the effective administration of Federal provisions primary to Federal program, and as otherwise necessary sions s that require other third parties payers to pay pr to administer these programs. For example, it may be necessary you have used to a hospital or doctor. Additional disclosures ecessary to disclose information about the benefits yyo are made through routine uses for information contained ained ined in systems of records. FOR MEDICARE CLAIMS: See the notice modifying Medicare Claims Record,’ published in the Federal Register, Vol. 55 fying ying system No. 09-70-0501, titled, ‘Carrie ‘Carrier Medic No. 177, page 37549, Wed. Sept. 12, 1990, orr as updated and republished. FOR OWCP CLAIMS: Department of Labor, or, r, Privacy Act of 1974, “Republication of Notice o of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28, 1990, See ESA-5, ESA-6, ESA-12, ESA-13, A-13, ESA-30, or as updated and republished. medical care provided by civilian sources and to issue payment upon establishment FOR CHAMPUS CLAIMS: PRINCIPLE LE PURPOSE(S): SE(S): ( ) To evaluate eligibility for me medica of eligibility and determination thatt the services/supplies pplies received are authorized b by law. ROUTINE USE(S): Information n from claims and related documents may be give given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/or the Dept. of Transportation consistent responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation of onsistent with their statutory administrative respon the Secretary of Defense in private collection agencies, and consumer reporting agencies in connection with recoupment n civil actions; to the Internal Revenue Service, pr priva claims; and to Congressional sional onal Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other federal, state, business entities, and individual providers of care, on matters relating to entitlement, claims e, local, cal, foreign government agencies, private bu bus adjudication, fraud,, program assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and m abuse, utilization review, quality assura criminal litigation n related to the operation of CHAMPUS. DISCLOSURES: information will result in delay in payment or may result in denial of claim. With the one exception discussed RES: Voluntary; however, owever, failure to provide informa below, there refusing to supply information. However, failure to furnish information regarding the medical services rendered re are no penalties under nder these programs for refusi refusin or the amount under these programs. Failure to furnish any other information, such as name or claim number, would delay mount charged would prevent payment of cclaims un payment information under FECA could be deemed an obstruction. ent of the claim. Failure to provide medica medical inform It iss mandatory that you tell us if you know that a another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801anothe information. 3812 provide penalties for withholding this info inform “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches. You should be aware that P.L. 100-503, the “Com “Comp S MEDICAID PAYMENTS (PROVIDER CERTIFICATION) are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnish I hereby agree to keep such record records as a information regarding any paymen payments cclaimed for providing such services as the State Agency or Dept. of Health and Human Services may request. I further payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception urther her agree to accept, as paym payme of authorized coinsurance, co-payment or similar cost-sharing charge. uthorized d deductible, coinsu SIGNATURE PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were TURE URE OF PHYSICIA personally me or my employee under my personal direction. y furnished by m certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State NOTICE: This is to cert funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services R FACT SHEET Medicare Billing: 837P and Form CMS-1500 What are the 837P and Form CMS-1500? Medicare FFS Contractors include The 837P (Professional) is the standard format used by health care A/B Medicare Administrative professionals and suppliers to transmit health care claims Contractors (MACs) and Durable electronically. The Form CMS-1500 is the standard paper claim form Medical Equipment (DME) MACs. to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers. Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (08/05) and the form is referred to throughout this fact sheet as the CMS-1500. ANSI ASC X12N 837P The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional) Version 5010A1 is the current electronic claim version. To learn more, visit the ASC X12 website on the Internet. ANSI = American National Standards Institute ASC = Accredited Standards Committee X12N = Insurance section of ASC X12 for the health insurance industry’s administrative transactions 837 = Standard format for transmitting health care claims electronically P = Professional version of the 837 electronic format Version 5010A1 = Current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers. The National Uniform Claim Committee (NUCC) has developed a crosswalk between the ASC X12N 837P and the hard copy claim form located on the Internet. Medicare FFS Contractors may also include a crosswalk on their websites. CPT Disclaimer-American Medical Association (AMA) Notice CPT only copyright 2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN 006976 March 2013 Page 1 Implementation and Companion Guides for Electronic Transactions ASC X12N Implementation Guides are the specific technical instructions for implementing each of the adopted HIPAA standards and provide instructions on the content and format requirements for each of the standards’ requirements. Implementation Guides are written for use by all health benefit payers, not specifically for Medicare. Implementation Guides, including Version 5010 Consolidated Guides, are found at on the Internet. Companion Guides are issued by CMS and health plans in an effort to provide the most up-to-date information related to how standard transactions must be submitted to that specific plan. Medicare Companion Guides provide further instructions identified as situational in an Implementation Guide and are accessed by visiting the Medicare Fee-for-Service Companion Guides web page. Medicare Claims Submissions The “Medicare Claims Processing Manual” (Internet-Only Manual Publication [IOM Pub.] 100-04) is found on the IOM web page. This publication includes instructions on claims submission. Chapter 1 includes general billing requirements for various health care professionals and suppliers. Other chapters offer claims submission information specific to a health care professional or supplier type. Once in IOM Pub. 100-04, look for a chapter(s) applicable to your health care professional or supplier type and then search within the chapter for claims submission guidelines. For example, Chapter 20 is entitled “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).” Visit Chapter 24 to learn more about electronic filing requirements, including the Electronic Data Interchange (EDI) enrollment form that must be completed prior to submitting Electronic Media Claims (EMCs) or other EDI transactions to Medicare. Refer to Chapter 26 to learn what should be included in the 837P or in each item of the CMS-1500. The “Medicare Benefit Policy Manual” (IOM Pub. 100-02) and the “Medicare National Coverage Determinations (NCD) Manual,” (IOM Pub. 100-03) both include coverage information that may be helpful in claims submission. Search for coverage guidance once within a chapter. Coding Correct coding is key to submitting valid claims. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available. Chapter 23 of the “Medicare Claims Processing Manual” is entitled “Fee Schedule Administration and Coding Requirements” and includes information on diagnosis coding and procedure coding, as well as instructions for codes with modifiers. Diagnosis Coding The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), is currently used to code diagnostic information on claims. The United States Go ...
Purchase answer to see full attachment

Tutor Answer

School: UC Berkeley


flag Report DMCA

Thanks, good work

Brown University

1271 Tutors

California Institute of Technology

2131 Tutors

Carnegie Mellon University

982 Tutors

Columbia University

1256 Tutors

Dartmouth University

2113 Tutors

Emory University

2279 Tutors

Harvard University

599 Tutors

Massachusetts Institute of Technology

2319 Tutors

New York University

1645 Tutors

Notre Dam University

1911 Tutors

Oklahoma University

2122 Tutors

Pennsylvania State University

932 Tutors

Princeton University

1211 Tutors

Stanford University

983 Tutors

University of California

1282 Tutors

Oxford University

123 Tutors

Yale University

2325 Tutors