Claim Submission Erros

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TrailBlazer Health Enterprises
Education Makes the Difference
Claim Submission Errors
Kelly Langford
Provider Outreach and Education
(866) 237-4482
Published April 2012
112685
© 2012 TrailBlazer Health Enterprises®/TrailBlazer®. All rights reserved.
Important
The information contained in this presentation
was current as of March 2012 and can be found
in the CMS-1500 Claim Form and
Unprocessable/Rejected Claims manual. All
manuals can be downloaded from:
http://www.trailblazerhealth.com/Publications/Manuals/
© CPT codes, descriptions, and other data only are copyright 2011 American Medical Association. All rights reserved.
Applicable FARS/DFARS clauses apply.
Slide 2
Agenda
• Discuss 5010 updates and reminders.
• Highlight the top claim submission errors for
November 2011 through January 2012.
• Discuss common Medicare Remittance Advice
(MRA) codes seen on claim rejections.
• Provide resolutions for each claim rejection.
• Convey the importance of filing Medicare claims
correctly the first time, every time, which results in
better cash flow for providers.
• Provide instructional resources.
Slide 3
TrailBlazer Health Enterprises
Education Makes the Difference
Updates and Reminders
2013 Electronic Prescribing Payment
Adjustment
Slide 5
Additional Resources
• CMS Electronic Prescribing (eRx) Overview.
https://www.cms.gov/ERxIncentive/01_Overview.as
p
• Quick Reference Guide for Understanding the 2012
eRx Payment Adjustment.
https://www.cms.gov/ERxIncentive/Downloads/QR
Guide_Understanding_2012eRxPayAdj_F01-092012_508.pdf
Slide 6
ASC X12 Version 5010
On March 15, 2012, CMS announced that it will not initiate
enforcement action until July 1, 2012, with respect to ASC
X12 Version 5010. This means that non-compliant covered
entities will not incur monetary fines until July 1, 2012.
TrailBlazer will not reject compliant ASC X12 4010 claims
prior to July 1, 2012. The exact date non-compliant 5010
claims will reject will be published at a later date.
CMS encourages providers to continue testing and take the
next step to move into production for 5010 billing.
Slide 7
ASC X12 Version 5010 (Cont.)
5010 HIPAA Implementation Guides:
• Institutional (Part A) Electronic Claim (837I).
• Professional (Part B) Electronic Claim (837P).
• Electronic Remittance Advice (835).
• Claim Status and Response (276/277).
• Eligibility Inquiry and Response (270/271).
Side-by-side comparisons (4010A1  5010):
http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp
Slide 8
ASC X12 Version 5010 (Cont.)
The HIPAA-compliant version of PC-ACE Pro32 is available on the Software
& Manuals Web page.
http://www.trailblazerhealth.com/Electronic Data Interchange/Software Manuals
Consult your software vendor, clearinghouse or billing service to ensure they
have tested and your software version is compliant prior to contacting the
Electronic Data Interchange (EDI) Technology Support Center.
You do not have to test if your vendor has tested and is compliant.
If you have any questions, please call the EDI Technology Support Center at
(866) 749-4302.
Slide 9
ASC X12 Version 5010 (Cont.)
Providers can stay abreast of important ASC X12 Version 5010
information by visiting the TrailBlazer EDI Web page. Valuable online
educational materials are only a mouse click away.
http://www.trailblazerhealth.com/Electronic Data Interchange/5010.aspx
The following resources are helpful:
• ASC X12 837 5010 Move-to-Production Procedures.
• HIPAA 5010 835 Production ERAs.
• Notices relating to 5010 implementation and transition.
• Online resource links (e.g., CMS 5010 Web page, Companion Guide,
FAQs, 5010 job aids).
Slide 10
ASC X12 Version 5010 – 835 for Part B
TrailBlazer is currently accepting requests to transition your ERA receiver IDs to the HIPAA 5010
production remittance. If you have already transitioned to 5010 for the 837 claims submission, you still
need to send a request to transition your 835 files as well because these are two separate processes.
Also, if you are only running your ERA files through Medicare Remit Easy Print (MREP), we still need
your request to transition your ERA receiver IDs to the HIPAA 5010 version.
If you are ready to transition to the HIPAA 5010 version, please fax a signed letter on
facility/company letterhead informing us that you are ready to convert to the HIPAA 5010 version for
the 835 claims submission. Please ensure you include the ERA receiver IDs that you want
transitioned.
Fax: (469) 372-1045
If you have any additional questions/concerns, please call any of the following numbers for further
assistance:
(866) 528-1605
(866) 528-1606
Slide 11
TrailBlazer Health Enterprises
Education Makes the Difference
Claim Submission Errors
Unprocessable/Rejected Claims
An unprocessable claim is any claim with
incomplete or missing required information, or
any claim that contains complete and
necessary information but the information
provided is invalid.
Slide 13
Unprocessable/Rejected Claims (Cont.)
In each rejection situation, the MRA will reflect a CO-16
message. This message reads as follows:
CO 16: Claim/service lacks information which is needed for
adjudication.
In addition to the CO-16 message, providers need to review the
MRA for additional messages that will explain why the claim
rejected. In some instances, there may be more than one
message that is needed to explain the reason for the claim
rejection. The CO-16 message should cue providers that the
next step is claim research and timely claim resubmission.
Slide 14
Unprocessable/Rejected Claims (Cont.)
Rejected/unprocessable claims will also reflect an additional
message (MA130) on the MRA:
MA130: Your claim contains incomplete and/or invalid
information, and no appeal rights are afforded
because the claim is unprocessable. Please submit a
new claim with complete/correct information.
This message directs providers to the appeal rights for the
individual claim along with a message to submit the claim with
corrected information.
Slide 15
PERF PROV SERV DATE POS NOS PROC MODS BILLED ALLOWED DEDUCT COINS GRP/RC-AMT PROV
PD
NAME
MA15
DOE, JOHN
XXXXX
1125 112508
HIC XXXXXXXXXA ACNT 22284-1
24
1
18699 SGT5
655.00
ICN 1505214XXXXXX ASG Y MOA MA130
0.00
0.00
0.00 CO-16 655.00
0.00
0.00
0.00
0.00
0.00
REM: M20
PT RESP
0.00
CLAIM TOTALS
655.00
655.00
0.0 NET
_________________________________________________________________________________________________
Remark Code
CO-16
Message
MOA Codes
Top Rejections
November 2011 – January 2012
1.
Patient eligibility.
2.
Referring or ordering physician (Item 17).
3.
Procedure code incomplete/missing/invalid.
4.
Billing provider information.
5.
Clinical Laboratory Improvement Amendments (CLIA).
Slide 17
Top Rejections (Cont.)
November 2011 – January 2012
6.
Medicare Secondary Payer (MSP).
7.
Claim not covered by this payer/contractor.
8.
Patient signature.
9.
Days/units.
10.
Where services furnished (Item 32).
Slide 18
Patient Eligibility
Rejection messages:
140
Patient/insured health identification
number and name do not match.
MA61 Missing/incomplete/invalid Social
Security number or health insurance
claim number.
Slide 19
Patient Eligibility Requirements
• The patient’s name and Medicare number should
be obtained during patient registration and
screening and reverified periodically to maintain
current and accurate patient information.
• It is critical for the patient’s information to be
shown/entered on the claim correctly (paper or
electronically).
Slide 20
Patient Eligibility
* Required field
Slide 21
Patient Eligibility (Cont.)
* Required field
Slide 22
Patient Eligibility Rejection Solutions
• Patient screening is vital in
capturing the necessary
information for correct claim
submission.
• Verify the patient’s name and
Medicare number to his
Medicare card.
• Make a copy of the patient’s
Medicare card for office
reference.
• Periodically re-verify the
patient’s eligibility.
• The Patient Registration and
Screening Guide provides ways
to implement a process or
improve existing processes. It is
located on the TrailBlazer Web
site under Publications/Manuals.
• The Interactive Voice Response
(IVR) provides patient eligibility
and benefit information.
• Incorporate the use of the
Patient Screening/Eligibility
Checklist located on the
TrailBlazer Web site under
Publications/Forms.
Slide 23
Instructional Resources
• Patient Registration and Screening Guide.
http://www.trailblazerhealth.com/Publications/Training
Manual/PatientRegistrationScreening.pdf
• IVR Web page.
http://www.trailblazerhealth.com/Customer
Service/Interactive Voice Response
• IVR Operating Guide.
http://www.trailblazerhealth.com/Publications/Job
Aid/IVR Operating Guide.pdf
• Part B Patient Screening/Eligibility Checklist.
http://www.trailblazerhealth.com/Publications/PDF
Form/PatientScreeningEligibilityChecklist.pdf
Slide 24
Referring or Ordering Physician
Rejection messages:
N264
Missing/incomplete/invalid ordering provider name.
N265
Missing/incomplete/invalid ordering provider
primary identifier.
N285
Missing/incomplete/invalid referring provider
name.
N286
Missing/incomplete/invalid referring provider
primary identifier.
Slide 25
Referring or Ordering Physician (Cont.)
Item 17: Enter the name of the referring or ordering physician if the service or item
was ordered or referred by a physician. All physicians who order or refer Medicare
beneficiaries must report this data. When a claim involves multiple referring and/or
ordering physicians, a separate Form CMS-1500 must be used for each
ordering/referring physician.
Referring physician: A physician who requests an item or service for the
beneficiary for which payment may be made under the Medicare program.
Ordering physician: A physician or, when appropriate, a non-physician practitioner
who orders non-physician services for the patient such as diagnostic laboratory
tests, clinical laboratory tests, pharmaceutical services or durable medical equipment
and services “incident to” that physician’s or non-physician practitioner’s service. See
Internet-Only Manual (IOM) Pub. 100-02, Medicare Benefit Policy Manual, Chapter
15, for non-physician practitioner rules.
Slide 26
Referring or Ordering Physician (Cont.)
The following services/situations require the
submission of the referring/ordering provider
information:
• Medicare-covered services and items that are the
result of a physician’s order or referral.
• Parenteral and enteral nutrition.
• Immunosuppressive drug claims.
• Hepatitis B claims.
• Diagnostic laboratory services.
Slide 27
Referring or Ordering Physician (Cont.)
• Diagnostic radiology services.
• Portable X-ray services.
• Durable medical equipment.
• When the ordering physician is also the performing
physician (as often is the case with in-office clinical
laboratory tests).
• When a service is “incident to” the service of a
physician or non-physician practitioner, the name of the
physician or non-physician practitioner who performs
the initial service and orders the non-physician service
must appear in Item 17 or the electronic equivalent.
Slide 28
Referring or Ordering Physician (Cont.)
+ Conditional field
Note: Item 17a or the electronic equivalent should be left blank.
Slide 29
Instructional Resources
• Use the “Electronic Claims Crosswalk to the
CMS-1500 Claim Form” job aid to view all of the
necessary loops and segments needed to file an
electronic claim to Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Trai
ning Manual/claim form instructions.pdf
Slide 30
Procedure Code Incomplete/
Missing/Invalid
Rejection messages:
4
The procedure code is inconsistent with the modifier used, or
a required modifier is missing.
M51
Missing/incomplete/invalid procedure code(s).
M20
Missing/incomplete/invalid HCPCS.
N56
Procedure code billed is not correct/valid for the services
billed or the date of service billed.
Slide 31
Procedure Code Requirements
* Required field
Slide 32
Procedure Code Solutions
• If the narrative description cannot be defined on the
claim, an attachment to the claim will be accepted
to provide additional information related to the
unlisted or Not Otherwise Classified (NOC) code
(Item 19 on the CMS-1500 claim form).
• Comment field for electronic claims.
Slide 33
Procedure Code Solutions (Cont.)
SE1138 – “Non-Specific Procedure Code Description Requirement for
HIPAA Version 5010 Claims”
The 5010 versions of the institutional and professional claim implementation
guides mandate that when claims use non-specific procedure codes, a
corresponding description of the service is now required.
Please ensure:
• Billing and coding staff follow these requirements for submitting a HIPAAcompliant claim when non-specific procedure codes are used.
• These implementation guide requirements are followed when submitting a
HIPAA-compliant claim for all non-specific procedure codes.
A complete listing of the NOC code set is available on the CMS Web site.
Slide 34
Procedure Code Solutions (Cont.)
http://www.cms.gov/ElectronicBillingEDITrans/40_FFSEditing.asp
Slide 35
Procedure Code Solutions (Cont.)
• Item 24d of the CMS-1500 claim
form or the electronic equivalent
should reflect the specific
procedure code.
• Maintain an up-to-date CPT
and/or HCPCS manual to assist
with correct procedure code
selection.
• The CMS-1500 Claim Form
manual will help with claim
submission requirements.
• The “Part B Crosswalk to the
CMS-1500 Claim Form” job aid
will help with the necessary
electronic loops/segments.
• Remember, the use of unlisted
procedure codes or NOC codes
should include a narrative
description of the procedure in
Item 19 of the claim form or the
electronic equivalent.
Slide 36
Instructional Resources
• Maintain an up-to-date CPT and/or HCPCS manual to assist
with correct procedure code selection.
• View the CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/claim form instructions.pdf
• Claims requiring additional documentation can be filed
electronically and the additional information can be faxed or
mailed to Medicare by using the Fax/Mail Documentation
Instructions and Cover Sheet.
http://www.trailblazerhealth.com/Publications/PDF Form/FaxMailEMCDocForms.pdf
Slide 37
Instructional Resources (Cont.)
• Use the “Part B Crosswalk to the CMS-1500 Claim
Form” job aid to view all of the necessary loops and
segments needed to file an electronic claim to
Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• SE1138 – “Non-Specific Procedure Code
Description Requirement for HIPAA Version 5010
Claims.”
http://www.trailblazerhealth.com/Tools/Notices.aspx
?ID=14729
Slide 38
Billing Provider Information
MRA Rejection Messages
N256 Missing/incomplete/invalid billing provider/supplier name.
N257 Missing/incomplete/invalid billing provider primary identifier.
N258 Missing/incomplete/invalid billing provider/supplier address.
N290 Missing/incomplete/invalid rendering provider primary
identifier.
Slide 39
Billing Provider Information (Cont.)
The performing provider and/or the billing
provider (solo provider or group practice,
depending on the type of practice) is always
required for claims processing.
Billing Provider Information
Slide 40
Billing Provider Information (Cont.)
Group practice billing example:
Slide 41
Billing Provider Information (Cont.)
* Required field
Slide 42
Billing Provider Information (Cont.)
Note: Item 33b is no longer used by Medicare.
* Required field
Slide 43
Instructional Resources
• Use the “Part B Crosswalk to the CMS-1500 Claim
Form” job aid to view all of the necessary loops and
segments needed to file an electronic claim to
Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• View the CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Traini
ng Manual/claim form instructions.pdf
Slide 44
CLIA – Item 23
Rejection messages:
MA120 Missing/incomplete/invalid CLIA number.
MA128 Missing/incomplete/invalid Food and Drug
Administration (FDA) approval number.
MA50
Missing/incomplete/invalid Investigational
Device Exemption (IDE) number for FDAapproved clinical trial services.
Slide 45
CLIA – Item 23 (Cont.)
Item 23: Prior Authorization Number
• Enter the Quality Improvement Organization (QIO) prior authorization number
for those procedures requiring QIO prior approval.
• Enter the IDE number when an investigational device is used in an FDAapproved clinical trial. The Post-Market Approval number should also be placed
here when applicable.
• For physicians performing Care Plan Oversight (CPO) services, enter the sixdigit Medicare provider number of the Home Health Agency (HHA) or hospice
when procedure code G0181 (home health) or G0182 (hospice) is billed.
Note: Until further notice, do not submit an HHA or hospice provider number when
billing for CPO services. Submission of the home health or hospice provider number
will result in the services being returned as unprocessable. Further information can
be found in IOM Pub. 100-04, Change Request (CR) 4374, Transmittal 999.
Slide 46
CLIA – Item 23 (Cont.)
+ Conditional field
Slide 47
CLIA – Item 23 (Cont.)
+ Conditional field
Slide 48
Instructional Resources
• Use the “Electronic Claims Crosswalk to the CMS-1500
Claim Form” job aid to view all of the necessary loops
and segments needed to file an electronic claim to
Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/claim form instructions.pdf
• Laboratory and Pathology manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/Lab-Path.pdf
Slide 49
Medicare Secondary Payer (MSP)
MSP claim rejections
continue to be one of the
top claim rejections for all
states and all provider
types. Patient screening
is the only way to identify
instances where
Medicare could be the
secondary payer.
Slide 50
MSP Rejection Messages
MA04
Secondary payment cannot be considered without the identity of or
payment information from the primary payer. The information was either not
reported or was illegible.
N155
Alert: Our records do not indicate that other insurance is on file. Please
submit other insurance information for our records.
MA83
Did not indicate whether we are primary or secondary payer.
N541
Mismatch between the submitted insurance type code and the information
stored in our system.
MA88
Missing/incomplete/invalid insured’s address and/or telephone number for
the primary payer.
MA89
Missing/incomplete/invalid patient’s relationship to the insured for the
primary payer.
Slide 51
MSP Claim Information
• Medicare closely screens all MSP claims to ensure that
information was accurate and consistent with the Common
Working File (CWF).
• MSP claims must be submitted with accurate primary
insurance information to ensure the result is an accurate
Medicare payment.
• Medicare verifies each claim with CWF, including the patient
name, Medicare number, eligibility, MSP benefits and other
key eligibility items.
• Patient screening is more important than ever to submit
MSP claims correctly to Medicare.
Slide 52
MSP Claim Information (Cont.)
Claims filed for Medicare secondary payment must be
submitted with accurate primary insurance information to
ensure the result is an accurate Medicare payment. For
example, use of an incorrect MSP type code could result in a
claim rejection. The valid MSP type codes are:
•
•
•
•
•
•
•
•
12 – Working Aged.
13 – End Stage Renal Disease (ESRD).
14 – Auto/Med/No-Fault Liability.
15 – Workers’ Compensation.
41 – Federal Black Lung.
42 – Veterans Affairs.
43 – Disability.
47 – Other Liability.
Slide 53
MSP Claim Rejection Example
The CWF reflects Medicare is primary payer.
• The provider submitted the claim indicating “other liability” (MSP
type 47), which indicates that there should be an open liability
accident record, but the date of the accident was not included on
the claim and none of the diagnosis codes submitted appear to
be accident-related.
The claim rejected due to the conflicting MSP liability
information submitted on the claim. The claim type “liability”
was not consistent with any accident type of diagnosis and no
date of accident was provided on the claim. The claim
diagnosis codes were reflective of the surgery performed but
not of any type of accident.
Slide 54
MSP Rejection Solutions
• Patient screening is vital in
capturing necessary information for
correct claim submission.
• The Patient Registration and
Screening Guide provides ways to
implement a process or improve
existing processes.
• The IVR provides patient eligibility
and benefit information.
• The “Part B Crosswalk to the CMS1500 Claim Form” job aid helps with
the necessary electronic
loops/segments for MSP
requirements.
• The CMS-1500 Claim Form manual
will help with claim submission
requirements.
• The Medicare Secondary Payer
(MSP) manual provides detailed
MSP provision information and MSP
payer type codes along with the
required electronic loops/ segments
and instructions for billing.
• Incorporate the use of the Patient
Screening/Eligibility Checklist.
• The Coordination of Benefits
Contractor (COBC) can assist with
MSP situations where there is a
possible conflict. Providers can call
(800) 999-1118.
Slide 55
Instructional Resources
• Patient Registration and Screening Guide.
http://www.trailblazerhealth.com/Publications/Training
Manual/PatientRegistrationScreening.pdf
• IVR Web page.
http://www.trailblazerhealth.com/Customer
Service/Interactive Voice Response
• Online Services computer inquiry system.
http://www.trailblazerhealth.com/Electronic Data
Interchange/Claim Status - Eligibility
• “Part B Crosswalk to the CMS-1500 Claim Form” job aid.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
Slide 56
Instructional Resources (Cont.)
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/claim form instructions.pdf
• Medicare Secondary Payer (MSP) manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/MSP.pdf
• COBC information.
http://www.cms.gov/COBGeneralInformation/01_Overview.a
sp
• Part B Patient Screening/Eligibility Checklist.
http://www.trailblazerhealth.com/Publications/PDF
Form/PatientScreeningEligibilityChecklist.pdf
Slide 57
Claim Not Covered by This
Payer/Contractor
Rejection messages:
109
Claim not covered by this payer/contractor.
N104 This claim/service is not payable under our claims jurisdiction area.
You can identify the correct Medicare contractor to process this
claim/service through the CMS Web site at http://www.cms.gov/.
N127 This is a misdirected claim/service for a United Mine Workers
(UMWA) beneficiary. Please submit claims to them.
N105 This is a misdirected claim/service for a Railroad Retirement Board
(RRB) beneficiary. Submit paper claims to the RRB carrier: Palmetto
GBA, P.O. Box 10066, Augusta, GA 30999. Call (866) 749-4301 for
RRB Electronic Data Interchange (EDI) information for electronic
claims processing.
Slide 58
UMWA Rejection Solutions
United Mine Workers of America (UMWA) is a multi-employer
insurance plan that funds health and pension benefits for
retired coal miners and their eligible dependents.
All claims for Medicare Part B services provided to Medicareeligible beneficiaries must be submitted to the “funds” for
payment. Services will automatically deny (regardless of
diagnosis) when billed to Medicare for beneficiaries entitled to
UMWA insurance.
Individuals with questions about the UMWA may call
(800) 291-1425.
Slide 59
Railroad Retirement Medicare
Rejection Solutions
Railroad Retirement
Railroad retirement beneficiaries have a prefix in front of the Health
Insurance Claim (HIC) number instead of a suffix after it. The number itself
has either six digits or the regular nine digits.
Example: A # # # # # # # # #
Send claims for railroad retirees to:
Palmetto GBA – Railroad Medicare
P.O. Box 10066
Augusta, GA 30999-0001
Do not send these claims to TrailBlazer.
Slide 60
Instructional Resources
• Patient Registration and Screening Guide.
http://www.trailblazerhealth.com/Publications/Training
Manual/PatientRegistrationScreening.pdf
• IVR Web page.
http://www.trailblazerhealth.com/Customer
Service/Interactive Voice Response/
• Claim Status and Eligibility Web page.
http://www.trailblazerhealth.com/Electronic Data
Interchange/Claim Status - Eligibility
• Part B Patient Screening/Eligibility Checklist.
http://www.trailblazerhealth.com/Publications/PDF
Form/PatientScreeningEligibilityChecklist.pdf
Slide 61
Instructional Resources (Cont.)
• Medicare Secondary Payer (MSP) manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/MSP.pdf
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/claim form instructions.pdf
Slide 62
Patient Signature
MA75
Missing/incomplete/invalid patient or
authorized representative signature.
Slide 63
Patient Signature Requirements
The patient or authorized representative must sign and enter either a six-digit date,
an eight-digit date or an alphanumeric date unless the signature is on file. In lieu of
signing the claim, the patient may sign a statement to be retained in the provider,
physician or supplier file in accordance with Chapter 1, “General Billing
Requirements,” of IOM Pub. 100-04. If the patient is physically or mentally unable to
sign, a representative may sign on the patient’s behalf. In this event, the statement’s
signature line must indicate the patient’s name followed with “by,” the
representative’s name, address, relationship to the patient and the reason the patient
cannot sign. The authorization is effective indefinitely unless the patient or the
patient’s representative revokes this arrangement.
Note: This can be “Signature on File” for paper or electronic claims. A computergenerated signature will be accepted for electronic claims only.
The patient’s signature authorizes release of medical information necessary to
process the claim. It also authorizes payment of benefits to the provider of service or
supplier when the provider of service or supplier accepts assignment on the claim.
Signature by Mark (X) – When an illiterate or physically handicapped enrollee signs
by mark, a witness must enter his name and address next to the mark.
Slide 64
Instructional Resources
• Use the “Electronic Claims Crosswalk to the
CMS-1500 Claim Form” job aid to view all of the
necessary loops and segments needed to file an
electronic claim to Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Trai
ning Manual/claim form instructions.pdf
Slide 65
Days/Units
M53 Missing/incomplete/invalid days or
units of service.
Enter the number of days or units. This field is most
commonly used for multiple visits, units of supplies,
anesthesia minutes or oxygen volume. If only one
service is performed, the numeral “1” must be
entered.
Slide 66
Days/Units Requirements
* Required field
Slide 67
Days/Units Solutions
Some services require that the actual number or quantity billed be clearly indicated
on the claim form (e.g., multiple ostomy or urinary supplies, medication dosages or
allergy testing procedures). When multiple services are provided, enter the actual
number provided.
For anesthesia, show the elapsed time (minutes) in Item 24g. Convert hours into
minutes and enter the total minutes required for this procedure.
For instructions on submitting units for oxygen claims, see IOM Pub 100-04, Chapter
20, Section 130.6 on the CMS Web site.
Beginning with dates of service on or after January 1, 2011, for ambulance mileage
enter the number of loaded miles traveled rounded up to the nearest tenth of a mile
up to 100 miles. For mileage totaling 100 miles and greater, enter the number of
covered miles rounded up to the nearest whole number miles. If the total mileage is
less than one whole mile, enter a zero before the decimal (e.g., 0.9). See IOM Pub.
100-04, Chapter 15, Section 20.2 for more information on loaded mileage and
Section 30.1.2 for more information on reporting fractional mileage.
Slide 68
Instructional Resources
• Use the “Electronic Claims Crosswalk to the CMS-1500 Claim Form” job
aid to view all of the necessary loops and segments needed to file an
electronic claim to Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training Manual/claim
form instructions.pdf
• Anesthesia manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/anesthesia.pdf
• Ambulance manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/Ambulance.pdf
• CMS Internet-Only Manuals (IOMs).
http://www.cms.gov/Manuals/IOM/list.asp
Slide 69
Where Services Furnished
(Item 32)
Rejection messages:
MA114 Missing/incomplete/invalid information on where the
services were furnished.
N256
Missing/incomplete/invalid billing provider/supplier name.
N258
Missing/incomplete/invalid billing provider/supplier address.
N293
Missing/incomplete/invalid service facility primary identifier.
Slide 70
Item 32 Requirements
Item 32:
Enter the name, address and ZIP code of the service
location for all services other than those furnished in
place of service home – 12.
Effective for claims processed on or after January 1,
2011, submission of the location where the service
was rendered is required for all place of service codes
including home – 12.
Slide 71
Item 32 Requirements (Cont.)
Slide 72
Verify ZIP Code Extension From
USPS Web Site
Slide 73
Item 32 Requirements (Cont.)
Slide 74
Instructional Resources
• CMS-1500 Claim Form manual.
http://www.trailblazerhealth.com/Publications/Training
Manual/claim form instructions.pdf
• MLN Matters® Article MM6947.
http://www.cms.gov/MLNMattersArticles/downloads/MM694
7.pdf
• Use the “Electronic Claims Crosswalk to the CMS-1500
Claim Form” job aid to view all of the necessary loops and
segments needed to file an electronic claim to Medicare.
http://www.trailblazerhealth.com/Publications/Job
Aid/Crosswalkto1500ClaimForm.pdf
Slide 75
Reminder – Place of Service
An improper payment exists when physicians bill
services with an incorrect place of service based on
the setting in which the services were rendered.
Place of service codes and descriptions can be found
on the CMS Web site at:
http://www.cms.gov/place-of-servicecodes/20_Place_of_Service_Code_Set.asp
Slide 76
Place of Service (Cont.)
As a result of incorrect billing of the
place of service, numerous
overpayments are identified through
various means of claims review. It is
important to report the claim based
on where the patient was
seen/treated.
A published list of valid places of
service can be found in the CMS1500 Claim Form manual on the
TrailBlazer Web site.
http://www.trailblazerhealth.com/Pub
lications/Training Manual/claim form
instructions.pdf
Excerpt from the places of service
listing:
11 – Office
12 – Home
21 – Inpatient hospital
22 – Outpatient hospital
23 – Emergency room
24 – Ambulatory Surgery Center
(ASC)
31 – Skilled Nursing Facility (SNF)
32 – Nursing facility
81 – Independent laboratory
99 – Other listed facility
Slide 77
Place of Service Example
Facility Versus Non-Facility
A patient was admitted to an inpatient hospital stay on June 21 and was
discharged on July 19.
The physician billed CPT code 99291© (critical care, first hour) for Date of
Service (DOS) June 23, with a place of service code 11. CPT code 99291
has a site of service differential. CPT code 99291 has a non-facility allowed
amount of $257.90 and a provider paid amount of $206.32. DOS June 23 is
during the inpatient hospital stay, and data analysis confirms that the patient
was not on a leave of absence from the hospital on that date. The correct
place of service code for this service date is 21.
The allowed amount for CPT code 99291 for the facility rate is $213.37. The
provider paid amount is $170.70. This results in an overpaid amount of
$35.62.
Slide 78
Questions
Slide 79
TrailBlazer Health Enterprises
Education Makes the Difference
Claim Submission Errors
Thank you for attending.
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