Revised CMS-1500 Health Insurance Claim Form (02/12)

Transcription

1 Revised CMS-1500 Health Insurance Claim Frm (02/12) Effective July 1, 2014, prfessinal claims submitted via paper billing must be submitted n the new 02/12 versin f the CMS-1500 Health Insurance Claim Frm, revised February Claims submitted n ther versins f the CMS-1500 frm will be returned unprcessed. The purpse f this Quick Tip is t prvide an verview f the changes t cmpletin instructins fr the CMS-1500 frm by cmparing the ld 08/05 versin t the new 02/12 versin. In several instances, the name has changed, but cmpletin fr Medical Assistance (MA) will nt change. The main changes are related t diagnsis cdes and 21 f the CMS-1500 frm. Expanded t accept up t twelve diagnsis cdes that may be a maximum f seven characters in length. Requires an indicatr t specify if the diagnsis cdes used are ICD-9-CM (indicatr 9 ) r ICD- 10-CM (indicatr 0 ) cdes. Claims may nt cntain bth ICD-9 and ICD-10 cdes n the same claim frm. Currently, the diagnsis cdes are shwn as items 1 thrugh 4 listed in tw clumns. The revised CMS-1500 frm lists the diagnsis cdes as items A thrugh L, brken ut int three rws. The primary thrugh furth cdes shuld be entered in the first rw acrss -- identified as A thrugh D; The fifth thrugh eighth cdes shuld be entered in the secnd rw acrss -- identified as E thrugh H; The ninth thrugh twelfth cdes shuld be entered in the third rw acrss -- identified as I thrugh L. Fr specific instructins based n prvider type and/r service, please refer t the PA PROMISe Billing Guides lcated in Appendix A f the 837 Prfessinal/CMS-1500 Frm Handbk. The billing guides can be accessed frm the PROMISe Prvider Handbks and Billing Guides page f the Department f Public Welfare s (the department s) website at the fllwing link: These guides will be updated prir t the implementatin f the revised CMS-1500 frm. NOTE: Changes have als been made t the MA 539 (CMS-1500 Medicare Attachment) due t sequestratin. When entering attachment type 05 in 19 f the CMS-1500 frm t bill MA fr Medicare Deductible r Cinsurance, a cmpleted MA 539 must accmpany the claim frm. The revised MA 539 frm and instructins can be fund n the department s website at the fllwing link:

2 Imprtant Ntes Upper Right Crner f the CMS 1500: D nt imprint, type, r handwrite any infrmatin in the upper right prtin f the claim frm. This area is used by the department t stamp the Internal Cntrl Number (ICN), which is vital t the prcessing f yur claim. Fnt Sizes: Because f limited field size, either f the fllwing type faces and sizes are recmmended fr frm cmpletin: Times New Rman, 10 pint Arial, 10 Pint Other fnts may be used, but ensure that all data will fit int the fields, r the claim may nt prcess crrectly. Handwritten claim frms: If yu are handwriting claim frms, please use blue r black ink. Laser and Inkjet Prduced claim frms & Phtcpies f claim frms: The department will nt accept phtcpies f claim frms r claim frms prduced by laser r inkjet printers. All claim frms must be riginal, with a red backgrund. Please nte that prviders can use laser r inkjet printers t print data nt the CMS-1500 frm; hwever, the claim frm must have the red backgrund. Name Patient Status 8 Optinal Other Insured s Date f Birth and Sex CMS-1500 Old (08/05) 9b Place an X in the apprpriate s t describe the patient s status. If a secndary insurance exists, enter the ther insured s date f birth. Please make sure the date is in an eight-digit MMDDCCYY (mnth, day, century, and year) frmat (e.g., ) and indicate the patient s gender by placing an X in the apprpriate bx Name CMS-1500 New (02/12) 8 9b Emplyer s Name r Schl Name Reserved Fr Lcal Use 9c 10d Enter the name f the ther insured s emplyer. This has tw uses: 1) It is ptinal t enter the nine-digit scial security number f the plicyhlder if the plicyhlder is nt Claim Cdes 9c 10d N change fr MA

3 Emplyer s Name r Schl Name Lcal Use r Nature f Illness r Injury 11b the recipient. 2) When billing fr an EPSDT Screen, enter the applicable tw-character EPSDT Referral Cde. Enter the name f the ther insured s emplyer fr the primary insurance. Cmplete with attachment type cdes, when applicable. See Billing Guide fr detailed instructins. When using AT05, indicating a Medicare payment, please cmplete and attach a "Supplemental Medicare Attachment fr Prviders" frm When using AT10, indicating a payment frm cmmercial Insurance, please cmplete and attach a "Supplemental Attachment fr Cmmercial Insurance fr Prviders" frm. Enter the mst specific three-, fur-r five-digit ICD-9-CM cde that describes the diagnsis. The primary ICD- 9-CM cde (21.1) must be cmpleted. The secnd, third, and furth diagnsis cdes must be cmpleted if applicable. Other Claim ID Additinal Claim Infrmatin r Nature f Illness r Injury 11b Leave blank Must/ (Added space fr ICD indicatr and ttal f 12 diagnsis cdes) N change fr MA. The ICD indicatr (ICD Ind) is required. If a valid 9 r 0 indicatr is nt entered int the ICD Ind space, claims will be returned as incmplete. Enter the mst specific ICD-9-CM cde (indicatr 9 ) r ICD-10-CM cde (indicatr 0 ) that describes the diagnsis. The primary diagnsis

4 Medicaid Resubmissin 22 This has tw uses: 1) When resubmitting a rejected claim. If resubmitting a rejected claim, enter tne 13-digit ICN f the ORIGINAL rejected claim in the right prtin f this (e.g., ). 2) When submitting a claim adjustment fr a previusly apprved claim. If submitting a claim adjustment, enter ADJ in the left prtin f the and the LAST APPROVED 13- digit ICN, a space and the 2-digit lint number frm the RA statement in the right prtin f the (e.g., ADJ ). Resubmissin 22 cde (21.A) must be cmpleted. The secnd thrugh twelfth diagnsis cdes (B-L) must be cmpleted if applicable. NOTE: D nt submit ICD-10-CM cdes r ICD Ind 0 n claims fr dates f service prir t Octber 1, N change fr MA. Pinter 24e Must This may cntain up t 4 digits. If the service was prvided fr the primary diagnsis (in 21,) enter 1. If Pinter 24e Must This may cntain up t 4 letters Enter the crrespnding letter(s) (A-L) that identify the diagnsis cde(s) in 21.

5 prvided fr the secndary diagnsis, enter 2. If prvided fr the third diagnsis, enter 3. Fr fr the furth diagnsis, enter 4. If the service prvided ws fr the primary diagnsis (in 21A,) enter A. If prvided fr the secndary diagnsis, enter B. If prvided fr the third thrugh twelfth diagnsis, enter the letter that crrespnds t the applicable diagnsis. NOTE: The primary diagnsis pinter must be entered first. Balance Due 30 Leave Blank D nt cmplete this. Rsvd fr 30. Thank yu fr yur service t ur Medical Assistance recipients. We value yur participatin. Check the department s website ften at: