Cms 1500 mcgraw hill

CHAPTER

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

10 Claim Management

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Learning Outcomes

When you finish this chapter, you will be able to:

10.1 Briefly compare the CMS-1500 paper claim and the

837 electronic claim.

10.2 Discuss the information contained in the Claim

Management dialog box.

10.3 Explain the process of creating claims.

10.4 Describe how to locate a specific claim.

10.5 Discuss the purpose of reviewing and editing claims.

10.6 Analyze the methods used to submit electronic

claims.

10-2

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Learning Outcomes (Continued)

When you finish this chapter, you will be able to:

10.7 List the steps required to submit electronic claims.

10.8 Describe how to add attachments to electronic

claims.

10.9 Explain the claim determination process used by

health plans.

10.10 Discuss the use of the PM/EHR to monitor claims.

10-3

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Key Terms

• adjudication

• aging

• claim status category

codes

• claim status codes

• claim turnaround time

• CMS-1500 (08/05) claim

• companion guide

• crossover claim

• data elements

• determination

10-4

• development

• filter

• HIPAA X12 837 Health

Care Claim

• HIPAA X12 276/277

Health Care Claim

Status Inquiry/Response

• insurance aging report

• medical necessity denial

• National Uniform Claim

Committee (NUCC)

• navigator buttons

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Key Terms (Continued)

• pending

• prompt payment laws

• suspended

• timely filing

10-5

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.1 Introduction to Health Care Claims 10-6

• Timely filing—health plan’s rules specifying the

number of days after the date of service that the

practice has to file the claim

• HIPAA X12 837 Health Care Claim—HIPAA

standard format for electronic transmission of

the claim to a health plan

• CMS-1500 (08/05) claim—mandated paper

insurance claim form

• National Uniform Claim Committee (NUCC)—

organization responsible for claim content

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.1 Introduction to Health Care Claims

(Continued) 10-7

• Data element—smallest unit of information in a

HIPAA transaction

• Notable features of the HIPAA 837 transaction

(as compared to the CMS-1500 paper form):

– It has many more data elements, though many are

conditional and apply to particular specialties only.

– It uses some different terms, and a few additional

information items must be relayed to the payer.

– It requires a claim filing indicator code.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.2 Claim Management in Medisoft

Network Professional 10-8

• Insurance claims are created, edited, and

submitted for payment within the Claim

Management area of MNP.

• Information contained in the Claim Management

dialog box:

– All claims that have already been created

– Status of existing claims

– Options for editing, creating, printing/sending,

reprinting, and deleting claims

• Navigator buttons—buttons that simplify the

task of moving from one entry to another

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.3 Creating Claims 10-9

• Claims are created in the Create Claims dialog

box of MNP; to create a claim:

– Click the Create Claims button in the Claim

Management dialog box; the Create Claims dialog

box will open.

– Apply the appropriate filters; any box that is not filled

in will default to include all data.

– Click the Create button to create the claims.

• Filter—condition that data must meet to be

selected

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.4 Locating Claims 10-10

To locate a claim in MNP:

– Click the List Only… button in the Claim Management

dialog box; the List Only Claims That Match dialog

box will be displayed.

– Apply the appropriate filters.

– Click the Apply button.

– The Claim Management dialog box is displayed,

listing only the claims that match the criteria that were

selected.

– Claims can now be edited, printed, or transmitted

from the Claim Management dialog box.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.5 Reviewing Claims 10-11

• Claims should be checked before transmission.

• Most PM/EHRs provide a way for billing

specialists to review claims for accuracy.

– In MNP, this task is accomplished by using the Edit

button in the Claim Management dialog box to load

the Claim dialog box.

• The more problems that can be spotted and

solved before claims are sent to carriers, the

sooner the practice will receive payment.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.6 Methods of Claim Submission 10-12

• Three most common methods of transmitting

electronic claims:

– Direct transmission to the payer—Claims created in

the PM/EHR are sent to the payer’s computer directly

via a connection.

– Direct data entry—A member of the provider’s staff

manually enters claims into an application on the

payer’s website.

– Transmission through a clearinghouse—Practices

send their claims to clearinghouses to be edited and

then sent to the payer; this is the method used by

most providers.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.6 Methods of Claim Submission

(Continued) 10-13

• Companion guide—guide published by a payer

that lists its own set of claim edits and formatting

conventions

• Crossover claim—claim billed to Medicare and

then submitted to Medicaid

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.7 Submitting Claims in Medisoft

Network Professional 10-14

To submit electronic claims in MNP:

– Select Revenue Management > Revenue

Management… on the Activities menu; the Revenue

Management window opens.

– Select Claims on the Process menu.

– Select an EDI receiver.

– To perform an edit check, click Check Claims; when

complete, the Edit Status column displays the status

of each claim.

– To continue with ready-to-send claims, select Send,

select Claims, and select the EDI receiver.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.7 Submitting Claims in Medisoft

Network Professional (Continued) 10-15

To submit electronic claims in MNP (continued):

– A claim file is created and a preview report is

displayed.

– If any errors are identified, the claims must be edited

before they can be transmitted.

– Click the Send button to send the claim files.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.8 Sending Electronic Claim

Attachments 10-16

• Attachments that accompany electronically

transmitted claims must be referred to in the

claim.

• In MNP, the EDI Report Area within the

Diagnosis tab of the Case dialog box is used to

indicate that there is an attachment and how it

will be transmitted.

– An attachment control number is required if the

transmission code is anything other than AA.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.9 Claim Adjudication 10-17

• Adjudication—series of steps that determine

whether a claim should be paid

– Initial processing—Data elements are checked by the

payer’s front-end claims processing systems.

– Automated review—Payers’ computer systems apply

edits that reflect their payment policies.

– Manual review—Claims with problems are set aside

for further review.

– Determination—Payer makes a decision about how to

handle a claim.

– Payment—If due, payment is sent to the provider.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.9 Claim Adjudication (Continued) 10-18

• Suspended—claim status when the payer is

developing the claim

• Development—process of gathering information

to adjudicate a claim

• Determination—payer’s decision about the

benefits due for a claim

• Medical necessity denial—refusal by a plan to

pay for a procedure that does not meet its

medical necessity criteria

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.10 Monitoring Claim Status 10-19

• Practices closely track their accounts receivable

using their PM/EHR.

• After claims have been accepted for processing

by payers, their status is monitored using the

PM/EHR.

• Monitoring claims during adjudication requires

two types of information:

– The amount of time the payer is allowed to take to

respond to the claim

– How long the claim has been in process

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.10 Monitoring Claim Status

(Continued) 10-20

• Prompt payment laws—state laws that

mandate a time period within which clean claims

must be paid

• Claim turnaround time—time period in which a

health plan must process a claim

• Aging—classification of accounts receivable by

length of time

• Insurance aging report—report that lists how

long a payer has taken to respond to insurance

claims

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.

10.10 Monitoring Claim Status

(Continued) 10-21

• HIPAA X12 276/277 Health Care Claim Status

Inquiry/Response—electronic format used to

ask payers about claims

• Claim status category codes—used to report

the status group for a claim

• Pending—claim status in which the payer is

waiting for information before making a payment

decision

• Claim status codes—used to provide a detailed

answer to a claim status inquiry

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