HMSA Basic Claims Filing for Health Insurance Claim Form (02-12) March 2016

Transcription

1 HMSA Basic Claims Filing for Health Insurance Claim Form (02-12) 1500 March 2016

2 Agenda CMS 1500-Interactive Tool CMS 1500 Manual Step-by-step Instruction Tips to prevent common errors Resubmissions Multi-page claims Contact information

3 Claims Filing Packet Helpful Claims Filing Links Mailing Claims to HMSA Sample of CMS-1500 (02-12) Getting Started with HHIN-Electronic Claims filing

4 Plan Types Commercial Plans PPO Choice of doctors HMO PCP coordinates health care Akamai Advantage HMSA s Medicare Advantage plan QUEST Integration HMSA s Medicaid managed care program

5 Plan Types Federal Employee Program (FEP) National BCBSA plan administered by HMSA Does not include HMSA s Federal Employees Health Benefits program - coverage code 087 BlueCard Members of other BCBS plans

6 Step-by-Step Instruction Eligibility Check eligibility at every encounter to verify your patient s coverage: HHIN: Call HMSA: PPO/HMO/Akamai Advantage: (Oahu) or (toll-free NI) QUEST Integration: (Oahu) or (toll-free NI) FEP: (Oahu) or (toll-free NI) BlueCard: BLUE (2583)

7 Step-by-Step Instruction Member ID The HMSA member ID card is an important source of information.

8 Health Insurance Claim Form 1500 (02-12) Step-by-Step TIP: HMSA s Provider Resource Center has an interactive claim form training tool er/cms1500_interactive_02_12. pdf

9 Health Insurance Claim Form 1500 (02-12) Step-by-Step The CMS 1500 was created by the National Uniform Claim Committee (NUCC) The detailed instructions including applicable code sets are available at: m_form_instruction_manual_2012_02-v3.pdf A few of HMSA s instructions are exceptions to information in the NUCC manual. Exceptions are identified in this presentation.

10 Health Insurance Claim Form 1500 (02-12) Step-by-Step Top Section Patient Information Block 1 Check group health plan Block 1a Enter the HMSA member ID. Copy the number exactly as it is shown, excluding the first 3 alpha characters (e.g., XLA or XLB ). For FEP and BlueCard enter the entire ID (do not exclude any alphas) Block 2 Indicate the patient s name last name, first name, middle initial. Do not use nick names

11 Health Insurance Claim Form 1500 (02-12) Step-by-Step Top Section Patient Information Block 3 Indicate the patient s birth date in MMDDYYYY format. Do not use slash (/) marks Block 4 Indicate the subscriber s name last name, first name, middle initial. The name must appear exactly as shown on the HMSA ID member ID card Block 5 Patient s address and phone number are optional. Exception: BlueCard and FEP require this information Block 6 Indicate the patient s relationship to the subscriber

12 Health Insurance Claim Form 1500 Top Section Patient Information Block 7 Insured s address and phone number are optional. Required by BlueCard and FEP (Federal Employees Program) Block 8 NUCC use

13 Health Insurance Claim Form 1500 Top Section Patient Information Block 9 Other Insured If Block 11d is a YES (another health plan), blocks 9, 9a and 9d must be completed. Note: This information is important in determining the order of coordinated benefit payment when the patient is covered by more than one health plan; Not applicable if another HMSA plan is secondary. Important: Coordination of Benefits The subscriber s plan is usually primary When both parents cover a child, the plan of the parent with the earliest birth month/day (MMDD) in the year is usually primary for the child

14 Health Insurance Claim Form 1500 Top Section Patient Information Blocks 9, 9a, and 9d are conditional on 11d being Yes Block 9b and 9c are for NUCC use

15 Health Insurance Claim Form 1500 Top Section Patient Information Block 10 Patient s Condition Block 10a An X must be entered in either the YES or NO box. If YES, the provider should bill Worker s Compensation (employment related) Block 10b An X must be entered in either the YES or NO box. If YES, the provider should bill the appropriate motor vehicle insurance carrier and indicate the State the accident happened Block 10c An X must be entered in either the YES or NO box. If YES, the provider should bill the appropriate liability insurance company and complete block 15

16 Health Insurance Claim Form 1500 Top Section Patient Information Block 10d Condition Codes (applies to Abortion, Sterilization or Worker s Compensation) review the condition codes at ontent&view=article&id=20&itemid=118 and place applicable codes in this area. If using more than one code allow 3 spaces between codes.

17 Health Insurance Claim Form 1500 Top Section Patient Information Block 11 N/A to HMSA; required by BlueCard Block 11a N/A to HMSA; required by BlueCard Block 11b N/A to HMSA; required by BlueCard Block 11c N/A to HMSA; required by BlueCard Block 11d an X must be entered in either the YES or NO box. If YES, Blocks 9, 9a, and 9d are required

18 Health Insurance Claim Form 1500 Top Section Patient Information Blocks 12 & 13 N/A to HMSA. HMSA does not accept assignment of benefits. HMSA pays participating providers directly. If a provider is not participating with HMSA, we pay the member, whether these blocks are signed or not Some providers enter text in these blocks that says Signature on File. This text will not change the way the claim is processed, but it will not do any harm if is it entered

19 Bottom Section Claim Specific Information Block 14 Enter the date of current illness, injury, or pregnancy. The date should be entered in MMDDYY format. No slash (/) marks. Enter the applicable qualifier code listed in NUCC manual to identify the date reported If an exact date is unknown for a chronic illness, enter an approximate date, or the date the physician first began treating the patient for the condition For preventive services, the date of service may be entered For accident-related services, the date of the accident should be entered For maternity-related services, the date of the last menstrual period (LMP), should be entered

20 Bottom Section Claim Specific Information Block 15 If other accident noted in block 10, be sure to indicate qualifier code 439 and date of accident; claim will reject if this information is not provided. Other NUCC Qualifier Codes are listed in the manual Block 16 N/A to HMSA

21 Bottom Section Claim Specific Information 4/12/

22 Bottom Section Claim Specific Information Block 17 Required for referred services. Enter the referring practitioner s first name and last name only. If you cannot fit the entire name in the field, use the first initial of the first name and the entire last name. Do not use a credential (e.g., "Dr." or "M.D") in the field. Leave blank if no referral received. BlueCard Claims - The name of the Provider and NPI are required for DME, independent clinical lab (ICL), and special pharmacy ancillary providers. Commercial Claims - The name of the referring (or ordering) provider is always required for laboratory or X-ray services, physical therapy, speech therapy, home IV therapy/infusion, and consultations. It s also required when a pharmacy is dispensing injectable drugs or when a DME supplier is dispensing DME equipment.

23 Bottom Section Claim Specific Information Block 17 If multiple providers are involved, enter one provider using the following priority order: 1. Referring Provider a provider who refers a patient to another provider. 2. Ordering Provider a provider who orders non-physician items such as DMEPOS, imaging and clinical laboratory services. 3. Supervising Provider Note: Enter the applicable qualifier to identify the provider reported. DN Referring Provider DK Ordering Provider DQ Supervising Provider

24 Bottom Section Claim Specific Information Block 17a Enter the referring provider s 10- digit HMSA number, if known. Leave the small block for ID qualifier blank Block 17b Then referring physician s NPI may be entered, if known, but is not used to process hard-copy claims Block 18 If the services billed were rendered during a hospital stay (e.g., hospital visit, surgery), the admission (FROM) date is required. The discharge (TO) date is optional

25 Bottom Section Claim Specific Information Block 19 This is the place to provide HMSA with any additional information that may be needed to process the claim correctly. Examples include: How a patient meets risk criteria Information about an accident Information about attachments Information about dosage or NDC number of injectable drugs

26 Bottom Section Claim Specific Information Block 20 N/A to HMSA Block 21 Enter the patient s primary diagnosis on line A, if the diagnosis is unknown, list the primary symptom or chief complaint. List pertinent secondary diagnoses on lines B-L. Enter the ICD indicator code to describe which version of ICD codes used: 9 ICD-9 CM (Services prior to 10/1/2015) 0 ICD-10 CM

27 Bottom Section Claim Specific Information Block 21 (continued) More tips Do not list rule out diagnoses. Be sure the diagnosis is appropriate to the gender and age of the patient. Effective October 1, 2015, only ICD-10 diagnosis codes will be accepted for services performed on and after October 1, 2015.

28 Bottom Section Claim Specific Information Block 21 (continued) when the patient is seen due to an accidental injury, diagnoses are entered to indicate the nature of the injury (e.g., sprained ankle) and where the injury occurred (e.g., home) More information may be entered in block 19 to explain the circumstances of the injury. Claims for injuries must include the appropriate ICD-10 code to describe the injury or external cause. (S,T, V, W, X, Y)

29 Bottom Section Claim Specific Information Block 22 Required to report replacement, resubmission and void claims. Enter the frequency code in the Resubmission Code block and enter the original claim ID# (found on the RTP) in the Original Ref. No. block. Resubmission Codes: 7 Replacement claim 8 Void claim

30 Bottom Section Claim Specific Information Block 23 If the service being billed required precertification, and precertification was obtained, enter the precertification number indicated in the approval letter Block 24 - Each service line has a shaded upper portion and an un-shaded lower portion. Do not use the upper and lower portions of each claim line, independently, to create additional service lines.

31 Bottom Section Claim Specific Information Block 24a Enter the date of service for each procedure or service provided in MMDDYY format using the FROM date portion. No slash (/) marks. Each service should be entered on a separate line For global surgical services, enter the date of the surgery For global maternity services use the date of delivery Do not bill for services not yet rendered

32 Bottom Section Claim Specific Information Block 24b Enter appropriate place of service (POS) code for each procedure or service provided. Double check to be sure the POS code matches the service provided Common POS codes are: 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 - Emergency

33 Bottom Section Claim Specific Information Block 24c EMG currently N/A for HMSA Block 24d Enter the CPT/HCPCS code for each service provided When applicable, enter one or more two-digit modifiers, as found in CPT or HCPCS, following the solid vertical line If more than one modifier is needed, enter modifier 99 in the first space, followed by up to 3 additional modifiers

34 Bottom Section Claim Specific Information Block 24d (continued) If you bill tax as a separate line item, use code S9999. To indicate the amount of another carrier s payment, use code Z9014. (Note: This code cannot be used on EDI claims.) When billing for injectable drugs, select the specific HCPCS to represent the drug. If a specific J code does not exist, use an unclassified drug code (e.g., J3490) and indicate the NDC number in the shaded area above the code. The shaded area above the codes on each line may also be used to indicate other supplementary information.

35 Bottom Section Claim Specific Information Injectable drug with a specific HCPCS: Injectable drug with a miscellaneous HCPCS: 4/12/

36 Bottom Section Claim Specific Information Block 24e Enter the diagnosis indicator reference letter (A, B, C, etc.) from block 21, that bests supports the procedure or service performed in order of relevance, separated by commas. Max of 4 dx pointers allowed, do not enter diagnosis range (i.e. A-D) Block 24f Enter a charge for each procedure or service performed in standard dollars and cents format, including the decimal point (e.g., 48.00) Amounts may also be entered for tax (S9999) and other carrier payment (Z9014) if applicable Amounts of $0.00 cannot be accepted

37 Bottom Section Claim Specific Information Block 24g Enter the number of services, visits, days or units for each service line. For anesthesia services, enter the appropriate duration in total minutes. For injectable drugs with specific J codes, enter the number of units based on the HCPCS description of the code. For injectable drugs that do not have a specific HCPCS code, the number of units will depending on how the products are dispensed.

38 Bottom Section Claim Specific Information Block 24h N/A for HMSA private business; but used by QUEST Block 24i N/A for HMSA Block 24j Enter Rendering Provider NPI ID# (applicable to locum tenens only) Block 25 N/A for HMSA Block 26 If a patient account number is entered, the information will be reflected on the provider s RTP

39 Bottom Section Claim Specific Information Block 27 N/A for HMSA private business; but required by BlueCard if the patient also has Medicare. Block 28 Enter the total of all charges from column 24F, minus any amount paid by another carrier Block 29 N/A for HMSA Block 30 N/A for HMSA; but required by BlueCard

40 Bottom Section Claim Specific Information Block 31 Paper CMS 1500 claims will be processed without the provider s signature or initials as long as the correct Provider ID number is entered in Block 33b. Block 32 If the service is rendered in a hospital, free-standing ASC, SNF or another type of facility (other than office or patient s home), enter the name and address of the facility.

41 Bottom Section Claim Specific Information Block 32a Optional for hard-copy claims Block 32b Optional for hard-copy claims. If entered, the HMSA provider number must consist of 10 digits. Important: Do not enter a two-digit ID qualifier in block 32b as indicated in the NUCC instructions. Inclusion of a two-digit qualifier will cause delays in claims processing.

42 Bottom Section Claim Specific Information Block 33 Enter the name of the rendering provider and the address (location) where the services were rendered. Block 33a Optional for hard-copy claims. Block 33b Enter the rendering provider s complete 10-digit HMSA number. Important: Do not enter a two-digit ID qualifier in block 33b as indicated in the NUCC instructions. Inclusion of a two-digit qualifier will cause delays in claims processing.

43 Tips to Prevent Common Errors Always use an original red line current claim form. Do not use black line photocopies. Use dark ink. Replace printer cartridges or toner when the type begins to fade. Never use highlighters or white out on the claim form. Type or computer generate using a minimum size 10 font. Do not try to squeeze more lines in by using smaller fonts.

44 Tips to Prevent Common Errors Proofreading is essential transpositions are common Double check member numbers and all procedure codes and diagnosis codes File claims promptly HMSA will accept claims 1 year from the date of service for processing To avoid processing delays and claim rejections, choose the correct 10-digit HMSA provider number and NPI for the location when submitting hardcopy claims Check to be sure all required fields are complete Remember to sign the claim form

45 (02-12) Step-by-Step How To Prepare a Resubmitted Claim There are many reasons why you may need to submit a corrected claim. Resubmitting for payment review Resubmitting a corrected claim Resubmitting a claim that has not been processed Resubmitting a claim for another reason

46 (02-12) Step-by-Step How To Prepare a Multi-Page Claim Label the # of claim forms in the top right corner of the form. Do not list a tax charge on each page. The tax charge should be listed as the last item on the last page. Do not list a total charge on each page. The total charge for all items should be listed on the last page only. On previous pages, type the word "continued" in Block 28. Staple all pages together at the center top of the page.

47 (02-12) Step-by-Step More Tips Photocopied forms are not accepted Rendering (24j) vs. billing (33b) provider Services that do not meet payment determination criteria Information is subject to change- please check the HMSA Resource Center, and E-library frequently for the most up-to-date information.

48 Contact Information HMSA Customer Relations (PPO, HMO, Akamai Advantage) on Oahu 1 (800) toll-free Neighbor Islands BlueCard Teleservice on Oahu 1 (800) toll-free Neighbor Islands Federal Employee Program (FEP) on Oahu 1 (800) toll-free Neighbor Islands and Mainland QUEST Integration Provider Service (Oahu) 1 (800) toll free Neighbor Islands 4/12/

49 Contact Information Requesting Hawaii Healthcare Information Network (HHIN) access 1 (808) Start filing electronic claims on Oahu or 1 (800) toll-free Neighbor Islands 4/12/

50 Mahalo! Living healthy and enjoying life to the fullest. That s what we re striving for. 4/12/