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MAP 105 Chapter 11 Powerpoint

MAP 105 Chapter 11 Powerpoint

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Map105 chapter 11 powerpoint Map105 chapter 11 powerpoint Presentation Transcript

  • UNDERSTANDING HEALTH INSURANCEA GUIDETO BILLINGAND REIMBURSEMENTMIRACOSTA COLLEGEMAP 105
  • Chapter 11Essential CMS-1500 ClaimInstructions•Apply optical scanning guidelines when completingclaims•Define general insurance billing guidelines•Enter patient and policyholder information•Enter physician or supplier information
  • Optical Scanning Guidelines•A scanner is used to convert printed characters into textviewed by an optical character reader (OCR)•All data must be entered within borders of the data field•Use Courier 10 or OCR10 type•Enter all alpha characters in upper case
  • Optical Scanning Guidelines(Cont)•Do not enter the alpha character “O” for a zero “0”•Do not use a hyphen except for the zip code•There are preprinted spaces for decimal points andparentheses, so do not add them
  • Optical Scanning Guidelines(Cont)•Only enter commas between the patient’s orpolicyholder’s last name, first name, and middle initial•Do not use other punctuation in a patient’s orpolicyholder’s name, except for a hyphen in a compoundname•Do not enter a patient’s or policyholder’s title, unlessprinted on the ID card
  • Optical Scanning Guidelines(Cont)•Birth dates are entered as eight digits – MMDDYYYY•Eight digits dates are used in Blocks 12, 14, 24 and 31•Nothing should be written in the upper right-hand half ofthe claim•Enter SIGNATURE ON FILE or SOF in Blocks 12 and/or 13
  • Reporting Diagnoses•The first listed code is the major reason the patient wastreated•Some chronic conditions should be coded if they affectthe patient’s medical management•Do not enter the decimal points, as they are pre-printedon the CMS claim form
  • Reporting Procedures inBlocks 24A – 24D•Block 24A – Dates of Service – MMDDYYYY•Block 24C – EMG – Some insurance carriers have aspecial emergency rider. If an emergency then mark aY(for yes)•Block 24D – CPT or HCPCS code for service provided
  • Reporting Procedures inBlocks 24D – 24F•Block 24D (Cont) – Modifiers are entered one blank spaceafter the CPT/HCPCS code without a hyphen•Block 24E – Diagnosis Pointer –There are numbers 1through 4 reported from Block 21. Enter the pointernumber not the ICD-9 code in Block 24E•Block 24F – Charges – Enter dollar amounts and cents
  • Reporting Procedures inBlocks 24G – 24J•Block 24G – Days or Units – Usually 1 unit is performed,unless identical procedures are reported on the same line•Block 24J – NPI – Enter the provider who performed theservice IF the provider is a member of a group practice.Leave blank if the provider is a solo practitioner. Or enterthe supervising provider if the service was provided by anonphysician practitioner.
  • Reporting Procedures inBlocks 25 – 28•Block 25 – National Standard Employer Identifier – Enterthe SS or EIN of the medical practice. Do not usehyphens•Block 27 – Accepts Assignment – Enter eitherY for yes orN for no to indicate if the practice accepts assignment.•Block 28 – Enter the total charges
  • Reporting Procedures inBlocks 29 – 31•Block 29 – Enter the amount another payer paid towardthe covered services. Do not enter the amount thepatient paid.•Block 30 – Enter amount due•Block 31 – Enter the provider’s name and credential.Enter the date the claim was submitted MMDDYYYY
  • Reporting Procedures inBlock 32•Block 32 – Enter the name and address of where serviceswere performed, if not in the provider’s office or patient’shome. Otherwise leave blank.•Block 32A – Enter the 10-digit NPI of the facility orsupplier entered in Block 32•Block 32B – Leave blank
  • Reporting Procedures inBlock 33•Block 33 – Enter the provider’s billing name, address, andtelephone number. No hyphens•Block 33A – Enter the 10-digit NPI of the billing provideror group practice•Block 33B – Leave blank