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- QUESTION
Write a 2 page paper about the CMS1500 claim form and the claims submission process.
Include the following:
1. An explanation of what the CMS1500 is and what it is used for.
2. Important dates and events in the creation and revision of the form.
• What version of the CMS-1500 became effective 1 October 2014?
• What were the major revisions on the CMS-1500 (08-05) version?
3. A description of the organization that developed the form.
4. A brief explanation of the claims process.
5. Definitions of the following terms, along with an example of each.
• Clean claim
• Rejected claim
• Pending claim
• Incomplete claim
• Invalid claim
• Dirty claim
• Deleted claim
6. A short description of the necessary components of a successful claim. Include discussion of demographics, authorizations, and clinical documentation.
| Subject | Business | Pages | 3 | Style | APA |
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Answer
CMS1500 Claim Form and The Claims Submission Process
- CMS1500 is the standard paper claim form deployed by Medicare Fee-For-Service (FFS) Contractors to bill insurance for any services and supplies rendered (Kliethermes, 2017).
- CMS1500 Form
- Version 02-12 of CMS1500 which became effective 1 October 2014 replaced the 08-05 version (Medicare.gov, 2019).
- One of the significant revisions to the CMS1500 (08-05) version was to provide for additional diagnosis codes. In specific, the providers were given the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes. Codes were increased from 4 possible ones to 12 (Medicare.gov, 2019).
- The CMS1500 form was created by the National Uniform Claim Committee (NUCC). Notably, the NUCC is a federal body established in 1995 to develop standardized data sets to be used by non-institutional healthcare community in their transmission of claims to and from third-party
- The claim process for filling manual claims under CMS1500 starts with printing out the form and completing it by hand (Kliethermes, 2017). The completed form is then checked to ensure that the documents are appropriately printed and the handwritten codes are correct and legible. The forms are then physically mailed to the payer who upon approval reimburses the non-institutionalized providers.
- Sources: Kliethermes, 2017; Medicare.gov, 2019.
- According to Medicare, a clean claim is that claim which is devoid of any defect, impropriety, or special circumstance such as incomplete documentation which can delay payment on time. For instance, a claim with the right codes and correct/accurate information is a clean claim.
- A rejected claim is under a rejected status because of failure in billing validations clearing house validations, or/and payer validations. For example, a form with missing or invalid other payer referring provider with ids will be rejected.
- A pending claim is that claim in an intermediate state where the payer indicates that they will update the claim status soon. A pending claim does not have an allocated status. For example, a claim which is neither clean, rejected, dirty, or even clean is under pending status.
- An incomplete claim is the claim under Medicare which has some missing/incomplete information. Additionally, an incomplete claim can have complete and necessary information, but the information is invalid. For instance, a claim which does not provide complete information as to the codes, institutional information, and other key data is an incomplete form.
- An invalid claim is a claim which although has complete and necessary information required for it to be processed, contains invalid information. For example, invalid information is that sets of data which is not acceptable such as invalid codes.
- A dirty claim is that claim which is submitted with errors that require manual processing to resolve the said problems or has been rejected for payment. For instance, a claim with incorrect information such as wrong coding.
- A deleted claim is an instance claim which the Medicare has either cancelled, deleted, or even voided by its fiscal intermediary. For example. Medicare may delete a claim because it cannot be amended or corrected due to the presenter of the claim committing fraud in the completion of the form.
- For a claim to be successful, it ought to be free from any defect and contain all the relevant information. It should be complete information as to the subscriber’s plan ID number and personal information, policy number, signature, among other details (Magellan Healthcare, 2016). Additionally, it should contain authorization from the physician who rendered the service and license number. Clinical documentation required for a successful claim include the date of current illness, previous illness, and referring provider, among other vital
References
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Kliethermes, M. A. (2017). Understanding health care billing basics. Pharmacy Today, 23(7), 57-68. Magellan Healthcare. (2016). Elements of A Clean Claim. Retrieved from https://www.magellanprovider.com/media/11924/f_cleanclaim.pdf Medicare.gov. (2019). How Do I File A Claim? Retrieved from https://www.medicare.gov/claims-appeals/how-do-i-file-a-claim
Appendix
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