MAP 105 Chapter 11 Powerpoint

1. UNDERSTANDING HEALTH INSURANCE
A GUIDETO BILLING
AND REIMBURSEMENT
MIRACOSTA COLLEGE
MAP 105

2. Chapter 11
Essential CMS-1500 Claim
Instructions
•Apply optical scanning guidelines when completing
claims
•Define general insurance billing guidelines
•Enter patient and policyholder information
•Enter physician or supplier information

3. Optical Scanning Guidelines
•A scanner is used to convert printed characters into text
viewed 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

4. 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 and
parentheses, so do not add them

5. Optical Scanning Guidelines
(Cont)
•Only enter commas between the patient’s or
policyholder’s last name, first name, and middle initial
•Do not use other punctuation in a patient’s or
policyholder’s name, except for a hyphen in a compound
name
•Do not enter a patient’s or policyholder’s title, unless
printed on the ID card

6. 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 of
the claim
•Enter SIGNATURE ON FILE or SOF in Blocks 12 and/or 13

7. Reporting Diagnoses
•The first listed code is the major reason the patient was
treated
•Some chronic conditions should be coded if they affect
the patient’s medical management
•Do not enter the decimal points, as they are pre-printed
on the CMS claim form

8. Reporting Procedures in
Blocks 24A – 24D
•Block 24A – Dates of Service – MMDDYYYY
•Block 24C – EMG – Some insurance carriers have a
special emergency rider. If an emergency then mark aY
(for yes)
•Block 24D – CPT or HCPCS code for service provided

9. Reporting Procedures in
Blocks 24D – 24F
•Block 24D (Cont) – Modifiers are entered one blank space
after the CPT/HCPCS code without a hyphen
•Block 24E – Diagnosis Pointer –There are numbers 1
through 4 reported from Block 21. Enter the pointer
number not the ICD-9 code in Block 24E
•Block 24F – Charges – Enter dollar amounts and cents

10. Reporting Procedures in
Blocks 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 the
service IF the provider is a member of a group practice.
Leave blank if the provider is a solo practitioner. Or enter
the supervising provider if the service was provided by a
nonphysician practitioner.

11. Reporting Procedures in
Blocks 25 – 28
•Block 25 – National Standard Employer Identifier – Enter
the SS or EIN of the medical practice. Do not use
hyphens
•Block 27 – Accepts Assignment – Enter eitherY for yes or
N for no to indicate if the practice accepts assignment.
•Block 28 – Enter the total charges

12. Reporting Procedures in
Blocks 29 – 31
•Block 29 – Enter the amount another payer paid toward
the covered services. Do not enter the amount the
patient paid.
•Block 30 – Enter amount due
•Block 31 – Enter the provider’s name and credential.
Enter the date the claim was submitted MMDDYYYY

13. Reporting Procedures in
Block 32
•Block 32 – Enter the name and address of where services
were performed, if not in the provider’s office or patient’s
home. Otherwise leave blank.
•Block 32A – Enter the 10-digit NPI of the facility or
supplier entered in Block 32
•Block 32B – Leave blank

14. Reporting Procedures in
Block 33
•Block 33 – Enter the provider’s billing name, address, and
telephone number. No hyphens
•Block 33A – Enter the 10-digit NPI of the billing provider
or group practice
•Block 33B – Leave blank