Claims & Formats

                                               Formats

1. Name Format:

Last Name, First Name followed by Middle initial. 

Example: Foster, Patrick. S

2. Date format:

MM/DD/YYYY

Example: 12 (December)/31 (Date)/2017 (Year)

3. Address Format:

Address 1: Street Information (Road Name, Street Name, Avenue Name etc)

Address 2: Apartment Information (Door Number, Building Name, Floor Number etc)

City, State, Zip Code: 5 digit Numeric

Zip Plus: 4 Digit Numeric

4. Contact Format:

10 Digit Numeric: 3-3-4

Example: 981-675-1234

5. Social Security Format:

9 Digit Numeric: 3-2-4

Example: 981-67-1234

6. TAX ID Format:

9 Digit Numeric: 2-7

Example: 98-6751234

6. NPI Format:

10 Digit Numeric: 10

Example: 9867512304

                                                   Claims

Claim:

Claim can be defined as a Predefined standard template where the demographic & charge details are entered & sent to the insurance company for payment.

Claim = Demographic Detail + Charge Details

Paper claims are sent through US Postal Service.

Electronic claims are sent through Internet.

Note: The difference between Paper and Electronic claims are follows:

** Electronic claims are confidential than paper claims.

** Electronic claims are fast.

** Electronic claims are costly when compared to paper claims.

CMS  = Centers for Medicare & Medicaid

UB     = Uniform Billing

ADA  = American Dental Association

NSF   = National Standard Format

ANSI = American National Standard Institute

NEA  = National Electronic Attachment

Note: When claims filed to the Federal / Govt. Insurance, we use NSF. For all the other Insurances we use ANSI.

Example:

CMS 1500 Claims form

CMS 1500 Claim Form

In this section we will discuss only about physician billing because Hospital billing and its claim form is vast. Also in this entire content I am explaining about only physician billing. Now we will see more about the CMS 1500 claims form.

3 Parts of Claim form:

The complete claim form is dived into 3 parts. First is carrier, second is patient and insured information. third is Physician or supplier information.

Carrier Code: In this section it will display or mention the carrier code.
Patient and insured information: In this section box number 1 to 13 is all about the patient and insureds information.
Physician or supplier information: In this section box number 14 to 33 b is all about Physician or supplier information.

Some of the important sections in claim form:

Generally the complete claim form with each and every box and lines are very important in order to process the claim successfully. Here some of the important area where claims gets rejected from payer side.

Box 1a: Invalide Insured ID number. Claims get rejected as payer can not identify the patient or Insured due to incorrect ID number.

Box 3:   Invalid Date of Birth (DOB) or Sex. Claims may rejected due to incorrect DOB mention on claim form. Claim also will get rejected if the sex of the patient does not match which is mentioned on the claim form.

Box 12: Signature is missing. Caims may get deny if the signature is missing in the Box 12. It should be written as Signature on file. Then only claims will get paid. This section helps to know that patient is aware about their health information will be released during processing the claim.

Box 13: It is important to be signed on claim form as then only provider or supplier gets payment from Insurance company on behalf of patient.

Box 22: Medicaid resubmission code. If the claim is submitted as corrected claim need to mention the claim number in Box number 22 with resubmission code as 7. 

Box 23: Need to mention authorization if the patient is visiting the specialist. In case of emergency it is not required. The POS in Box 24 B should be 23 for emergency service. 

Box 21: Invalid Dx (Diagnosis code) with patient age. Need to send the claim for coder's review. 

Box 24 J (Shaded Area): This are need to be filled with rendering provider's Taxonomy Code.

Box 24 J (Non-Shaded Area): This are is need to be filled with rendering provider's NPI. Invalid or missing either of them will render rejection of the claim.