Comparison Chart between different modifications CMS-1500 claims

Transcription

1 Fabiola Bounds Comparison Chart between different modifications CMS-1500 claims 1.- Modification to commercial primary CMS-1500 claim when the same commercial health insurance company provides a secondary or supplemental policy. 9 Enter the secondary or supplemental policyholder's last name, first name, and middle initial (if known) (separate by commas). Enter the secondary or supplemental policyholder's policy or group number Enter the name of the secondary or supplemental policyholder's commercial health insurance plan Enter an X in the YES box. 2.-Modifications to commercial primary CMS-1500 when a different commercial health insurance company provides a secondary or supplemental policy. NOTE: if the primary and/secondary /supplemental payers are the same, do not generate a second CMS-1500 claim. Instead, modify the primary CMS-1500 claim using instructions in table 12-2 Enter the secondary or supplemental policyholder's health insurance identification number (HICN) as it appear on the insurance card. Do not enter hyphens or spaces in the number. 4 Enter the secondary or supplemental policyholder last name, first name, and middle initial (separated by commas) 7 Enter the secondary or supplemental policyholder mailing address and telephone number. 9 Enter the primary policyholder's policy or group number. Enter the name of the primary policyholder commercial health insurance plan 11 Enter the secondary or supplemental policyholder's policy or group number. Do not enter hyphens or spaces in the policy or group number. 1 11c Enter the secondary or supplemental policyholder's birth date as MM DD YYYY. Enter an X in the appropriate box to indicate the policyholder's gender. If the policyholder's gender is unknown, leave blank. Enter the name of the secondary or supplemental policyholder's commercial health insurance plan. Enter a X in the YES box. 26 Add an S to the patient's account number to indicate the secondary policy.

2 3.- Modifications to BCBS primary CMS-1500 claims when patient is covered by same BCBS payer for primary and secondary or supplemental plans 9 Enter the secondary or supplemental policyholder's last name, first name, and middle initial (if known) (separated by commas) Enter the secondary or supplemental policyholder's policy or group number Enter the name of the secondary or supplemental policyholder's commercial health insurance plan. Enter an X in the YES box. 4.- Modifications to BCBS secondary CMS-1500 claims completion instructions when patient is covered by BCBS secondary or supplemental plan NOTE: If the primary and secondary payers are the same, do not generate a second CMS-1500 claim, refer to table 13-2 instructions Enter the secondary policyholder's BCBS identification number as it appear on the insurance card. Do not enter hyphens or spaces in the number. 4 Enter the secondary policyholder last name, first name, and middle initial (if known) separate by commas. 7 Enter the secondary policyholder mailing address and telephone number, Enter the street address on line 1, enter the city and state on line 2, and enter the five-or ninedigits zip code and phone number in lane 3. 9 Enter the primary policyholder last name, first name, and middle initial Enter the name of the primary policyholder health insurance plan (commercial health insurance plan name or government program). 11 Enter the secondary policyholder policy or group number. Do not enter hyphens or spaces in the policy or group number. 1 11c Enter the secondary policyholder birth date as MM DD YYYY. Enter an X in the appropriated box to indicate the policyholder gender, if gender is unknown, leave b Enter the name of the secondary policyholder BCBS health insurance plan. Enter an X in the YES box. 29 Enter the reimbursement amount received from the primary payer.

3 5.- CMS-1500 claims completion instructions for Medicare and Medigap claims 1 Enter an X in the Medicare and the other boxes 9 Enter SAME if the patient is the Medigap policyholder. If the patient is not the Medigap policyholder, enter the policyholder's last name, first, and middle name Enter MEDIGAP followed by the policy number and group number, separated by spaces ( e.g., MEDIGAP ) Enter Medigap Plan ID number. 13 Enter SIGNATURE IN FILE. Leave the date field blank. 6.- CMS-1500 claims completion instructions for Medicare-Medicaid (Medi-Medi) crossover claims 1 Enter a X in both the Medicare and Medicaid boxes. 10d Enter the abbreviation MCD followed by the patient's Medicaid ID number 27 Enter an X in the YES box. ( NonPAR providers must accept assignment on Medicare-Medicaid crossover claims.) 7.- CMS-1500 claims completion instructions for Medicare as secondary payer claims 1 Enter an X in Medicare and Other boxes 4 If the policyholder is the patient, enter SAME, if the patient is not the policyholder, enter the primary insurance policyholder's name. 6 Enter X in the appropriate box to indicate the patient's relationship to the primary insurance policyholder. 7 Enter SAME. 10a-10c Enter X in the appropriate boxes to indicate whether the patient's condition is related to employment or an auto or other accident. 11 Enter the primary policyholder group number if the patient is covered by a group health plan. Otherwise leave blank. 1 11c Enter the primary insurance policyholder date of birth as MM DD YYYY. Enter the appropriate box to indicate the policyholder's gender. Enter the name of the primary policyholder insurance plan. Enter X in the NO box. 16 If the patient is employed full time, enter the dates the patient is or was unable to work ( if applicable).

4 8.- CMS-1500 claims completion instructions for Medicare roster billing. 1 Enter X in Medicare box. 2 Enter SEE ATTACHED ROSTER. 11 Enter NONE. 20 Enter X in the NO box. 21 On line 1, enter V03,82 for PPV or V04.81 for influenza virus. 24B 24D Enter 60 (place of service, POS, code for mass immunization center). On line 1, enter for PPV or Q2305 for influenza virus (Afluria) On line 2, enter G0009 (administration code for PPV) or G0008 (administration code for influenza. Then, enter 33 as the modifier. 25 Enter the provider's EIN Enter X in the EIN box. 27 Enter X in the YES box. 29 Enter the total amount paid by Medicare beneficiaries. If not amount was paid, leave blank. 31 Have the provider sign the claim or use a signature stamp. Enter the date as MMDDYYYY. 32 Enter the provider's name and address. 32a Enter the provider's NPI 33 Enter the provider's name, address, and telephone number. 33a Enter the provider's NPI

5 9.- CMS-1500 claims completion for Medicaid as secondary payer 4 Enter the primary policyholder last name, first name, and middle initial. 6 Enter X in the appropriate box to indicate the patient's relationship to the primary policyholder. If the patient is an unmarried domestic partner, enter X in other box. 7 Enter the primary policyholder mailing address and phone number. Enter the street address on line 1, enter the city and state on line 2, and enter the five- or nine digit zip code and phone number in line 3. 9 Enter the primary policyholder last name, first name, and middle initial. If the primary policyholder's is the patient, enter SAME. Enter the primary policyholder policy or group. 10a-c 10d Enter the name of policyholder health insurance plan. Enter the X in the appropriate box. Leave Blank. 11 Enter the rejection code provided by the payer if the patient has other third-party payer coverage and the submitted claim was rejected by that payer. Otherwise leave blank. Enter a X in YES box. 28 Enter the total charges for services and/or procedures reported in Enter the amount paid by the other payer, if the other payer denied the claim, enter CMS-1500 claims completion instructions for Medicaid mother/baby claims Enter the mother's Medicaid ID number as it appears on the patient's Medicaid card. 2 Enter the mother last name followed by the word NEWBORN (separate by a comma) EXAMPLE: VANDENRMARK, NEWBORN 3 Enter the infant's birth name(separate by a comma), followed by (MOM), as the responsible party. EXAMPLE: VANDENRMARK, JOYCE (MOM) 21 Enter ICD-10-CM secondary diagnosis codes in fields B through L, if applicable.

6 11.- CMS-1500 claims completion instructions for SCHIP claims 1 Enter an X in Other box. Enter SCHIP identification number (assigned by the health plan) of the subscriber (person who holds the policy). 29 Enter the total amount the patient (or another payer) paid toward covered services only, if not payment was made, leave blank Modifications to CMS-1500 claims completion instructions when TRICARE is the secondary payer. 11 and 1-11c remain blank on a TRICARE as secondary CMS-1500 claim Enter the secondary policyholder health insurance identification number (HICN) as it appears on the insurance card. 4 Enter the TRICARE as secondary policyholder last name, first name, and middle initial. 7 Enter the TRICARE as secondary policyholder mailing address and phone number. 9 Enter the primary policyholder last name, first name, and middle initial 11, 1-c Leave blank. Enter the primary policyholder policy or group number. Enter the name of the primary policyholder's health insurance plan Enter X in YES box 29 Enter the reimbursement amount received from the primary payer. Attach the remittance advice received from the primary payer on the CMS-1500.

7 13.- Modification to TRICARE primary CMS-1500 claims completion instructions when patient has a supplemental health plan. 1 Enter X in the TRICARE and OTHER boxes. 9 Enter the supplemental policyholder last name, first name, and middle initial 11, 1-c Leave blank Enter the supplemental policyholder's policy or group number. Enter X in the YES box Leave blank.