Guide for completing the CMS-1500 (Professional Claims) Form

Transcription

1 Guide for completing the CMS-100 (Professionl Clims) Form CCStp nd its ffilites offer this guide to help you complete the CMS-100 form for your ptients with CCStp coverge. In the event illing procedures chnge, we will keep you updted with Provider Bulletins or Quick Points. Coding guidelines for ll fields re outlined in this guide. Specil instructions identify required field nd opticl scnning requirements. Providers who sign prticiption greements with CCStp gree to sumit clims on ehlf of our memers. Required coding schemes re HCPCS for procedures nd ICD-9-CM for dignoses. A notice explining how we resolve ech clim is sent to the prticipting provider. Thnk you for using the guide when filing pper clims. It will llow CCStp to improve ccurcy nd timely processing of clims. 1

2 Required fields Required if pplicle Not Used 1 MEDICAID c c c 10d d d A through 24G shded section A 2 24 I B 2 D C E 26 2 G F J J H

3 Completing the CMS-100 Form Field Nme nd Numer Instructions = Required = Required if pplicle = Not used 1 MEDICARE Plce n X in the pproprite ox for the type of helth insurnce pplicle to this clim. If MEDICAID the other ox contins n X, complete field 1 with the primry coverge identifiction TRICARE CHAMPUS numer. If secondry coverge, refer to field 9. Mrk only one ox. CHAMPVA GROUP HEALTH PLAN FECA BLK LUNG OTHER 1 Insured s I.D. numer Enter insured s ID numer s shown on insured s ID crd for the pyer to whom the clim is eing sumitted. Do not include the ptient s two-digit memer numer t the end of the ID. 2 Ptient s nme Enter the ptient s lst nme, first nme nd middle initil s it ppers on the ID crd. 3 Ptient s irth dte Enter the ptient s eight-digit dte of irth in (MM DD CCYY) formt. Sex Plce n X in the pproprite ox to indicte the ptient s sex. Mrk only one ox. If gender is unknown, leve lnk. 4 Insured s nme Enter insured s lst nme, first nme nd middle initil. Ptient s ddress Enter the ptient s ddress, city, stte, zip code nd phone numer. If the ptient s phone numer is unknown leve lnk. Do not use punctution. Use two-digit stte code nd, if ville, nine-digit zip code. 6 Ptient reltionship Plce n X in the ox for self if the ptient is the insured, spouse if the ptient is the to insured insured s husnd or wife. If none of the ove pplies, plce n X to indicte child or other s pplicle. Mrk only one ox. Insured s ddress Enter the insured s ddress, city, stte, zip code nd phone numer. Do not use punctution. If insured s ddress or telephone numer is unknown, leve lnk. Use two-digit stte code nd, if ville, nine-digit zip code. Note: For Worker s Compenstion, use ddress of employer. 8 Ptient sttus Plce n X in the pproprite oxes. If the ptient is full-time student, complete field 11 if the informtion is ville. 9 Other insured s nme When dditionl group helth coverge exists, enter other insured s lst nme, first nme nd middle initil. Enter the employee s group helth insurnce informtion for Worker s Compenstion clims. 9 Other insured s policy or Enter the policy or group numer of the other insured s indicted. group numer 9 Other insured s dte of Enter the other insured s eight-digit dte of irth in (MM DD CCYY) formt. irth Sex Plce n X in the pproprite ox to indicte the other insured s sex. Mrk only one ox. If gender is unknown, leve lnk. 9c Employer s nme Enter the nme of the other insured s employer or school. or school nme 9d Insurnce pln nme Enter the other insured s insurnce pln or progrm nme. or progrm nme 10 Is ptient s condition Only one ox cn e mrked per sumission. relted to:. Employment. Plce n X in the pproprite ox. If yes, complete field 14. (current or previous). Auto ccident. Plce n X in the pproprite ox. If yes, indicte stte nd lso complete field 14. c. Other ccident c. Plce n X in the pproprite ox. If yes, complete field d Reserved for locl use Not used. 11 Insured s policy group Enter the insured s policy or group numer s it ppers on the ID crd if present. For Worker s or FECA numer Compenstion, enter the Worker s Compenstion pyer clim numer if ville. 11 Insured s dte of irth If known, enter the insured s eight-digit dte of irth in (MM DD CCYY) formt. If insured s dte of irth is unknown, leve lnk. Sex Plce n X in the pproprite ox to indicte the insured s sex. Mrk only one ox. If gender is unknown, leve lnk. 11 Employer s nme or Complete if full-time student. Enter the nme of the insured s employer or school. school nme 3

4 Field Nme nd Numer Instructions = Required = Required if pplicle = Not used 11c Insurnce pln nme Enter the insurnce pln or progrm nme of the insured. or progrm nme 11d Is there nother helth Plce n X in the pproprite ox. If yes, complete fields 9 through 9d. enefit pln? 12 Ptient s or uthorized Enter Signture on File, SOF or legl signture. When legl signture, enter dte person s signture signed. 13 Insured s or uthorized Enter Signture on File, SOF or legl signture. This uthoriztion will not e honored person s signture for in-stte non-prticipting providers. 14 Dte of current illness, Enter the first dte in six-digit (MM DD YY) or eight-digit (MM DD CCYY) formt of the injury, or pregnncy current illness, injury or pregnncy. For pregnncy, use the dte of LMP s the first dte. A dte is required if injury or emergency. 1 If ptient hs hd sme Enter the first dte in six-digit (MM DD YY) or eight-digit (MM DD CCYY) formt tht the or similr illness, ptient hd the sme or similr illness. Previous pregnncies re not similr illness. give first dte Leve lnk if unknown. 16 Dtes ptient unle to Enter dtes ptient is unle to work in six-digit (MM DD YY) or eight-digit (MM DD CCYY) work in current occuption formt. Leve lnk if unknown. 1 Nme of referring Enter the nme of the physicin or other source tht referred the ptient to the illing physicin or other source provider or ordered the test(s) or item(s). 1 Other ID # Enter the two-chrcter qulifier nd Other ID. For list of vlid two-chrcter qulifiers refer to the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. 1 NPI Enter the ten-digit NPI. 18 Hospitliztion dtes Enter the inptient hospitl dmission dte followed y the dischrge dte (if dischrge hs relted to current services occurred) using the six-digit (MM DD YY) or eight-digit (MM DD CCYY) formt. If not dischrged, leve dischrge dte lnk. 19 Reserved for locl use Not used. 20 Outside l? $Chrges For l services enter n X in Yes if the reported service(s) ws performed y n outside lortory. If yes, enter the purchse price. Enter n X in No if outside l service(s) is not included on the clim. 21 Dignosis or nture List up to four ICD-9-CM dignosis codes. Relte lines 1,2,3,4 to lines of service in 24E of illness or injury y line numer. Use the highest level of specificity. Do not provide nrrtive description in this ox. 22 Medicid resumission For Medicid resumission clims only. Enter the correct three-digit replcement reson code followed y the 1-digit TCN of the most current incorrectly pid clim. Refer to Medicid Mnul for code list. 23 Prior uthoriztion Enter the prior uthoriztion or service greement numer s ssigned y the pyer for the numer current service. 24A 24G Nrrtive Description Enter the supplementl informtion in the shded section of 24A through 24G ove the corresponding service line. If n unlisted code is used, nrrtive description must e present. 24A Dte(s) of service Enter the six-digit dte(s) of service in (MM DD YY) formt. If one dte of service only, enter tht dte under From. Leve To lnk or re-enter From dte. If grouping services, the plce of service, procedure code, chrge nd rendering provider for ech line must e identicl for tht service line. Grouping is llowed only if the numer of dys mtches the numer of units in 24G. 24B Plce of service Enter the two-digit code from the plce of service list in Appendix 2 in the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. 24C EMG EMG mens emergency. Enter Y for Yes or leve lnk for No. 24D Procedures, services, Enter HCPCS Level I codes (CPT), Level II codes (A-DMEPOS) nd modifiers. Up to or supplies four modifiers my e sumitted. 4

5 Field Nme nd Numer Instructions = Required = Required if pplicle = Not used 24E Dignosis code Enter dignosis pointer(s) referenced in field 21 to indicte which dignosis code(s) pply to the relted HCPCS code. Do not enter ICD-9-CM codes or nrrtive descriptions in this field. Do not use slshes, dshes, or comms etween reference numers. 24F $ Chrges Enter the chrge mount in (Dollrs Cents) formt. If more thn one dte or unit is shown in field 24G, the dollr mount should reflect the TOTAL mount of the services. Do not indicte the lnce due, ptient liility, lte chrges/credits or negtive dollr line. Do not use decimls or dollr signs. 24G Dys or units Enter the numer of dys or units on ech line of service. When determining units refer to Appendix 3 in the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. 24H EPSDT If relted to EPSDT enter Y for Yes with vlid referrl code. If not relted to EPSDT enter N for No. For list of vlid EPSDT (C&TC) referrl codes refer to the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. Fmily Plnning If relted to Fmily Plnning, enter Y for Yes or leve lnk for No. 24I ID Qulifier Enter the two-chrcter qulifier. For list of vlid two-chrcter qulifiers refer to the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. 24J Rendering Provider ID Enter the Other ID. 24J Rendering Provider ID Enter the ten-digit NPI. 2 Federl tx ID numer Enter your employer identifiction numer (EIN) nd plce n X in the EIN ox. If not ville, enter your Socil Security Numer (SSN) nd plce n X in the SSN ox. Only one ox cn e mrked. 26 Ptient s ccount numer Enter the ptient s ccount numer. 2 Accept ssignment? For ptients with Medicre coverge, plce n X in the pproprite ox. 28 Totl chrge Enter the sum of the chrges in column 24F (lines 1-6). Enter the totl chrge mount in (Dollrs Cents) formt. Do not use negtive numers. 29 Amount pid Enter pyment mount from the ptient or other pyer. An Explntion of Benefits my e required. 30 Blnce due Leve lnk. 31 Signture of physicin or Enter the signture of the physicin, provider, supplier or representtive with the supplier including degrees degree, credentils, or title nd the dte signed. or credentils 32 Service fcility loction Enter the nme nd ctul ddress of the orgniztion of fcility where services were informtion rendered if other thn ox 33 or ptient s home. Enter this informtion in the following formt: Line 1: nme of physicin or clinic Line 2: ddress Line 3: city, stte, zip code 32 NPI Enter the ten-digit NPI. 32 Other ID Enter the two-chrcter qulifier nd Other ID. For list of vlid two-chrcter qulifiers refer to the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul. 33 Billing provider info Enter this informtion in the following formt: nd phone numer Line 1: nme of physicin or clinic Line 2: ddress Line 3: city, stte, zip code Nme nd ddress is required. Phone numer is not required. If providing phone numer it must e entered in the re to the right of the ox title. The re code is entered in prenthesis; do not use hyphen or spce s seprtor. 33 NPI Enter the ten-digit NPI. 33 Other ID Enter the two-chrcter qulifier nd Other ID. For list of vlid two-chrcter qulifiers refer to the Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form mnul.

6 Opticl Scnning instructions Providers tht re electronic clim sumission enled need to sumit electroniclly. If you re unle to sumit electroniclly, mil scnnle pper clims. CCStp uses opticl scnner technology to ssist in the entry of pper clims into our processing system. Use of n opticl scnner improves ccurcy nd timeliness of clims processing. Specil instructions for completing the form re printed elow. Providers must sumit pper clims on the officil (i.e., forms tht meet Government Printing Office Specifictions) Drop-Red-Ink CMS-100 forms. We cnnot ccept lck-nd-white, fxed, or photocopied forms. Providers who preprint their nmes nd ddresses in field 33 should use 10 or 12 point font size. Print: - Use UPPERCASE chrcters only - The print should e 10 or 12 point font size. Do not use multiple font sizes on clim. This includes resumissions with corrected informtion. - Use stndrd fonts- typewritten (Courier). Don t use unusul fonts such s sns serif, script, ortor, itlics, etc. Avoid old or worn print nds/rions. Clims tht re too light cnnot e scnned. Enter ll informtion on the sme horizontl line. Enter ll informtion within the designted field. Do not hnd-write, or stmp nything on the clim form. Pin-feed edges need to e removed evenly t side perfortions. Avoid folding clims. A mximum of six line items re llowed per clim in field 24. Do not use specil chrcters such s slshes, dshes, deciml points, dollr signs, or prentheses. Mke sure the clim is ligned correctly nd the dt is within the ox. If informtion is not contined within the intended field, it my e returned. Stple ny multiple pge clims (with or without ttchments). If you re sumitting multiple pge clim, enter the totl clim mount only on the lst pge in field 28. Ensure ptient, suscrier nd provider informtion mtch exctly on preceding pges. Service The Customer Service deprtment offers providers informtion out clims, enefits, pyment, nd CCStp procedures. Informtion cn lso e found on our provider we self-service site t Min office: (61) or We site: Mil clims to: To order CMS-100 clim forms contct: Prticipting with Employer Provider Network Inc. (EPNI) U.S. Government Printing Office t (202) , CCStp locl printing compnies in your re, P.O. Box nd/or office supply stores. St. Pul, MN Non-Prticipting with Employer Provider Network Inc. (EPNI) CCStp P.O. Box St. Pul, MN Minnesot Stndrds for the Use of the CMS-100 Helth Insurnce Clim Form: The mnul cn e downloded from the AUC we site t F9322 (3/08) 6