Chapter 8: Claim Forms Flashcards
1
Q
Item 14 Qualifier is used to indicate what information?
A
Date of Current illness, Injury, or Pregnancy (LMP).
DO NOT enter a qualifier for MC claims
2
Q
What is the appropriate POS code to report services rendered in an UC Facility?
A
POS 20
3
Q
When 2 or more DX Codes reported in item 21 to support a procedure, how many DX Codes should the provider report in item 24E for Medicare claims?
A
1 – Per the Medicare Claims Processing Manual, enter only one reference number/letter per line item.
CMS states that when multiple services are performed, enter the primary reference number/letter for each service ONLY.
4
Q
What does the abbreviation FL refer to?
A
Form Locator on the UB-04 claim form
5
Q
When reporting procedure codes on the UB-04 claim form, what is FL46-Units of Service?
A
Indicated the number of times the procedure was performed
6
Q
When a provider “accepts assignment”, what happens to the difference between the charged amount and the allowed amount?
A
It is considered a contractual write-off
7
Q
Where can the guidelines for proper completion of claim forms be found?
A
Private payers website or Medicare Claims Processing Manual
8
Q
A patient is admitted to the hospital for pneumonia. Which FL would be used to repair the patients admitting diagnosis?
A
FL69 - Admitting Diagnosis
* required for inpatient claims
9
Q
What regulation requires claims to be sent electronically unless unusual circumstances are met?
A
Administration Simplification Compliance Act (ASCA)
10
Q
Facility charges are reported on which claim form?
A
UB-04
11
Q
Who can use the CMS 1500 claim form?
A
its for professional services performed by providers and ASCs
12
Q
What is Adjudication?
A
it is used to describe the process of determining the validity of a claim and the amount the insurer will pay on the claim after the members insurance benefits have been applied.
13
Q
What does NUCC stand for?
A
National Uniform Claim Committee
14
Q
What revisions does the CMS-1500 claim undergo?
A
- Multiple reviews
- Updates approved by NUCC
- Submitted to CMS for approval
- Awaits public comment through CMS & Office of Management and Budget
- Final approval & implementation
15
Q
What transactions are specified in the 5010 Electronic Transaction Standards?
A
Transaction Standards include:
(837) Claims: institutional, professional, dental, COB, & NCPDP
(276/277) Claims status inquiry/requests
(835) remittance
(834) Enrollment
(820) Premium payment
(270/271) Eligibility inquiry/response
(278) Referrals and PA
(277CA) Claims Acknowledgements
(999) Acknowledgment for Health Insurance
16
Q
For reporting multiple providers on the CMS-1500 form, what is the priority order and the qualifier?
A
- Referring Provider (Qualifier DN)
- Ordering Provider (Qualifier DK)
- Supervising Provider (Qualifier DQ)
17
Q
What is the type of bill code that is reported for a free-standing clinic?
A
073X
18
Q
What is the type of bill code that is reported for a OPT Clinic?
A
074X
19
Q
What is the type of bill code that is reported for a CORF Clinic?
A
075X
20
Q
What is the type of bill code that is reported for a Hospital Outpatient (ASC)?
A
083X
21
Q
What is the type of bill code that is reported for a Critical Access Hospital?
A
085X
22
Q
What is the type of bill code that is reported for a Hospital Outpatient?
A
013X
23
Q
What is the type of bill code that is reported for a Hospital Swing Bed?
A
018X
24
Q
What is the type of bill code that is reported for an ESRD Clinic?
A
072X
25
What is an Ordering Provider?
Physician or non-physician practitioner who orders non-physician services for the patient (DK)
26
What is a Supervising Provider?
The provider who provided oversight of the rendering provider and the care being reported. (DQ)
27
What is a Attending Provider?
The provider with overall responsibility for the patients medical care during hospitalization
28
What is a Referring Provider?
The provider who requests an item or service for the beneficiary. (DN)
29
The patient is a child covered under the fathers insurance policy. Which item on the CMS-1500 form is the father DOB listed?
11a - 8 digit DOB
30
Item 10 on the CMs-1500 form has 3 boxes to be completed that will provide liability information. What are the?
If they are related to:
Employment
Auto accident
other Accident
31
what is the correct format to enter the DOB on a PAPER CMS 1500 form? ELECTRONIC?
PAPER - MM/DD/CCYY
ELECTRONIC - CCYYMMDD
32
What is the specific EDI version for healthcare professionals and suppliers to transmit claims electronically?
ANSI ASC X12N 837P
33
What is the current version of the HIPPA electronic transaction standards for healthcare professionals and suppliers?
Version 5010A1
34
What are some exceptions that allow a paper claim to be filed to Medicare?
1. roster billing for inoculations
2. Medicare demonstration project that specifies paper submission
3. "Obligated to accept payment in full" (OTAF)
4. MSP - more than one primary payer
35
In ANSI ASC X12N 837P, what does ANSI stand for?
ANSI - American National Standards institute
36
In ANSI ASC X12N 837P, what does ASC stand for?
ASC - Accredited Standards Committee
37
In ANSI ASC X12N 837P, what does X12N stand for?
X12N - Insurance section of ASC X12
38
In ANSI ASC X12N 837P, what does 837P stand form?
837 - Standard format for transmitting healthcare claims electronically
P - Professional version of the 837 electronic format
39
If a patient has insurance primary to Medicare, which items must be completed in addition to Item 11?
items 4, 6, 7 and 11a-11c
40
How are the procedural charges on a UB-04 claim form sequenced?
by revenue code in ascending numerical order and not repeat.
41
What does the facility enter appropriately to identify specific accommodation and/or ancillary charges and in which box?
Revenue codes in FL 42 to explain each charge in FL 47.
*The last revenue code in FL 42 is 0001 = represents the grand total of all charges billed
42
To limit the number of line items on each bill, what should you do in FL42?
sum revenue codes at the "zero" level to the extent possible
43
Item 24D on the CMS 1500 claim form is used to report procedures, services, or supplies. How many modifiers can be added to item 24D?
4
44
For patients who have Medicare primary and secondary insurance, how is the secondary insurance filed?
IF it's a cross over insurance, Medicare will cross the claim over to the secondary payer
45
When an item is checked yes in boxes 10a -10c, what does this mean?
the claim may be covered by workers comp, auto insurance, or liability insurance
46
What is the process of applying the members insurance benefits to determine the insurers payment responsibility to a medical claim?
Adjudication
47
The assignment of benefits is confirmed if a patient signs which item?
item 13 - "signature on file" or "SOF" = authorizes payment of medical benefits to the physician or supplier
48
What is the purpose of the standard CMS1500 claim form?
bill professional services for physicians.
49
What item on the CMS 1500 claim form contains information regarding Medigap?
items 9, 9a, 9d
Item 9 = enter SAME is subscriber is pt or sub information
item 9a = policy/group number of secondary insurance preceded by MEDIGAP, MG, or MGAP)
item 9d = 9 digit payer id
50
When completing the CMS 1500 form, date(s) of service are found in item 24; a series of identical services were performed, and the claim was denied. What is the reason for the denial?
the DOS "from" and "to" dont match the number of units. each day =1 unit
51
In item 4 of the CMS 1500 form, what is entered on a Medicare claim when the patient has an insurance primary to Medicare and the patient is the insured?
SAME
52
Line 24B is for place of service. Where can the place of service codes be found?
Front of CPT book
53
FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?
Only for inpatient services. DO NOT complete on outpatient claims
54
When entering the patients name on the CMS 1500 form, what punctuation should be used?
Commas: last name, first name, middle initial
55
On the CMS 1500 claim form, which item number identifies the prior authorization or referral number?
Item 23 - can also place CLIA # here.
56
Who can electronic claims be submitted to?
provider directly to the payer or to a clearing house
57
How many digits should be entered in the DOB fields (items 3, 9b, and 11a)?
8-digit dates
58
How many digits should be entered in the non DOB date fields? (items 11b, 12, 14, 16, 18, 19, 24a and 31)
either 6 or 8-digit dates --- they must ALL be 6 digits or ALL be 8 digits
Items 12 & 31 are exempt from the requirement
59
What is an item on the electronic format of CMS1500?
Loop = Item
60
What goes in Item 5 on the CMS 1500?
Patients address
-NO punctuation
-permanent address not temporary (ex: at college)
61
What goes in Item 7 on the CMS 1500?
Insureds address
- SAME if pt is subscriber
- workers comp = employer address
62
The following goes in which box on the CMS 1500 form?
Claim codes
- claim codes to identify additional information about the patients condition
- condition codes approved for use in this box: abortion, sterilization, and workers comp
Item 10d on the CMS 1500 form
63
What item number does the policy group or FECA number go in?
Item 11 -- if item 4 is completed, you MUST include a group or FECA number
64
For work related injures, where of you enter the dates the patient is unable to work on a CMS 1500 form?
Item 16
65
What goes in item 17 on a CMS 1500 form? Item 17ab?
referring (DN), ordering provider (DK), or supervising physician (DQ)
IF the service or item was ordered or referred by a physician
17ab = NPI
66
On Item 17 of the CMS 1500 form, what order do you enter the providers in when you have multiple providers involved?
1. Referring provider (DN)
2. Ordering provider (DK)
3. Supervising provider (DQ)
67
On the CMS 1500 form, where can you enter additional claim information?
Item 19
-NOC drugs
- more than 4 modifiers on a line (mod 99 on the line item)
- PWK = paperwork
68
On the CMS 1500 form, where would you check off "yes" to indicate billing for purchased services?
Item 20: outside lab
69
What item number does the patient diagnosis/condition go in?
Item 21
- no decimals
-proper sequence
- ICD indicator
70
In what item number do you use to enter resubmission codes when resubmitting claims?
Item 22 - enter resubmission code and original reference/claim #
71
what goes in Item 23 on CMS 1500 form?
Authorization #, CLIA
72
What goes in Item 24, 24b, 24c, 24e, 24g, and 24h on the CMS 1500?
Item 24 - contains 6 service lines
Item 24b - Place of Service
Item 24c - EMG: E for emergency (medicaid); not all payers require. other payers Y or N
Item 24e - DX Pointer (dx code assignment)
Item 24g - Days/units
Item 24h - EPSDT Family Planning (Medicaid: Y or N)
73
What is another name for the UB-04 claim form used to report facility services?
CMS 1450
74
On the UB-04 form, where do you enter Billing Provider name, address and phone number? Billing providers pay to name, and address?
FL 1
FL2 - optional; billing providers pay to name and address
75
On the UB-04 form, what goes in FL 3a and FL 3b?
FL 3a = patient control number (financial records)
FL 3b = MRN (assigned by the facility)
76
What is a four digit alphanumeric code that gives three specific pieces of information after a leading Zero? Where does it go?
CMS ignores the leading Zero.
FL4 - Type of Bill
77
What is the Code Structure for when selecting the type of bill?
1st - zero (ignored by CMS)
2nd - type of facility (1st to CMS)
3rd - classification (clinics only)(2nd to CMS)
4th - frequency - definition (3rd to CMS)
78
On the UB-04 form, where does the Federal Tax number go?
FL5
79
Where can you find the period the statement covers on a UB-04 form?
FL 6
80
On the UB-04 form, where does the patient name, ID #, address, DOB and sex go?
FL 8 - pt name and ID #
FL 9 - patient address
FL 10 - DOB
FL 11 sex
81
On the UB-04 form, FL 12 - Admission/start of care date is required for what?
Inpatient, HH, Hospice and outpatient rehab/facility
82
On the UB-04 form, which FL are not used?
FL 7, 29, 30, 37, 38, 49
FL 52abc, 57, 68,71, 75, - not used
83
On the UB-04, which FL are not required?
FL13 - Admission hour
FL16 - Discharge hour
FL 55abc
84
On the UB-04 form, where does a provider enter the code indicating the source for the referral for the admission or visit?
FL15 point of origin for admission or visit
(ex: ER before pt was referred to transferred to inpatient)
85
On the UB-04 form, where do you enter the Priority type of admission and patient discharge status (2)?
FL 14 - priority type
FL 17 - patient discharge status
86
On the UB-04 form, where does the provider enter the corresponding code to describe any conditions or events that apply to the billing period?
FL 18-28 Condition codes
entered in ascending order; beginning with # then letters
87
On the UB-04 form, what goes in FL 31, 32, 33, and 34?
Occurrence codes and dates.
codes and dates defining specific events related to the billing period
code =2 alphanumeric digits
dates = 6 digits
88
On the UB-04 form, when occurrence code 04 accident employment related is entered, what does that indicate and where must you include a value code?
04 indicates a workers comp claim
include value code in FL 39-41 = another payer involved
89
Which FLs are required for inpatient claims only?
FL35 and 36 - occurrence SPAN code and dates
** not the same as FL 31-34 occurrence codes and dates
FL 69 - admitting dx
FL 74 - Principal procedure code and date
FL 74A-E - when other procedure codes and dates must be reported
90
On the UB-04 form, where are value codes and amounts entered?
FL 39, 40, 41
codes related to money or unit amounts
91
On the UB-04 form, where is the revenue code and revenue description entered?
FL 42 - revenue code
FL 43 revenue discription/medicaid drug rebate
92
On the UB-04 form, where do you enter the following?
1. HCPCS/Rates/ HIPPS Rate Codes
2. Service Date
3. Units
4. Total Charges
5. Non covered charges
1. FL 44
2. FL 45
3. FL 46
4. FL 47
5. FL 48
93
On the UB-04 form, where is the following entered?
1. payer ID
2. health plan ID
1. FL50abc
2. FL51abc
94
On the UB-04 form, where do you enter the following?
1. release of information indicator
2. prior payments
3. billing provider NPI
1. FL52abc
2. Fl 54abc
3. Fl 56
95
On the UB-04 form, where is the following entered?
1.Insureds name
2. relationship to insured
3. Member ID #
4. Group name
5. group #
1. FL 58abc - Insureds name
2. FL 59abc - relationship to insured
3.FL 60abc - Member ID #
4. FL 61abc - Group name
5. FL 62abc - group #
96
On the UB-04 form, where can you find the Authorization code?
FL 63abc
97
On the UB-04 form, where can you find the DCN placed by the payer?
FL64abc
98
On the UB-04 form, where do you enter the ICD indicator?
FL 66
99
On the UB-04 form, where do you enter the Attending Provider name and NPI when claim/encounter contains any services other than non scheduled transportation services?
FL76
100
On the UB-04 form, which 3 Secondary Identifier Qualifiers are used in FL 77, FL 78, & FL 79?
0B - State License Number
1G - Provider UPIN Number
G2 - Provider Commercial Number
FL77 - Operating Provider Number and ID (Required: surgical procedure code is on Claim)
FL 78 & 79 - Other Provider Name and ID
101
On the UB-04 form, 3 Secondary Identifier Qualifiers are used on which FLs?
FL 77 - operating provider ID (required for Surgical Codes)
FL 78 & 79 - Other Provider Name and ID
FL 80 - Remarks ( MC is secondary due to WC, liability or EGHP)
FL81 - Code-Code FL. (additional codes)
102
When billing on CMS 1500, Item 14, what do the qualifiers 431 & 484 represent?
Qualifiers :
431: Onset of Current Sx or Illness
484: LMP
103
When billing on CMS 1500, Item 14 or 15, Which qualifier is used to identify the dates of the Initial Treatment?
454 - Initial Treatment
104
When billing on CMS 1500, Item 14 or 15, What does the qualifier 439 represent?
439 - Accident
105
When billing on CMS 1500, Item 14 or 15, What do the qualifiers 455 and 471 represent?
455 - Last X-ray
471 - Prescription
106
When billing on CMS 1500, Item 14 or 15, Which qualifiers are used to represent the Start Date (Assumed Care) and the Report End (Relinquished Care)?
090 - Start Date (Assumed Care)
091 - Report End (Relinquished Care)
107
When billing on CMS 1500, Item 14 or 15, What qualifier is used to represent the date of the First Visit or Consultation? Latest Visit or Consultation?
444 - First Visit or Consultation
304 - Latest visit or consultation
108
When billing on CMS 1500, Item 14 or 15, What qualifier is used to represent the date of Acute Manifestation of a Chronic Condition?
453 - Acute manifestation of a chronic condition
109
On the CMS 1500 and UB-04 Claim Forms, what does the qualifier 0B identify?
0B = State License Number
110
On the CMS 1500 and UB-04 Claim Forms, what does the qualifier 1G identify?
1G = Provider UPIN Number
111
On the CMS 1500 and UB-04 Claim Forms, what does the qualifier G2 identify?
G2 = Provider Commercial Number
112
On the CMS 1500 and UB-04 Claim Forms, which provider can the qualifier LU: Location Number ONLY be used for?
Supervising Provider
113
What are Condition Codes used for on the UB-04 claim form?
Used to indicate an inpatient service is reported on an outpatient claim. ( numerical order)
ex: code 44 - inpatient services order but upon review services did not meet inpatient criteria and claim submitted as outpatient
114
FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span codes and dates. When is this section completed?
Only for Inpatient Services
115
On the UB-04 claim form, FL 10 is used to record the patient’s birthdate. If the birthdate is unknown, what information is entered?
eight zeros
116
Which form locator(s) on the UB-04 claim form reports the main reason for the encounter?
FL 67 - principal dx code
117
When is Item 7 completed?
only when Item 4 is completed. (subscriber is not pt)
118
On the UB-04 claim form, what is entered in FL 50A when Medicare is determined to be the primary payer?
Medicare
FL50A-C - payer identification
119
If a patient has insurance primary to Medicare, which Items must be completed in addition to Item 11?
Items 4, 6, 7, and 11a-11c
120
In Item 4 of the CMS-1500 claim form, what is entered on a Medicare claim when the patient has an insurance primary to Medicare and the patient is the insured?
SAME
