Claim Guidelines

837P

The electronic CMS-1500 claim format (also known as the ANSI ASC X12N 837P) used to submit claims for professional services rendered by health care providers.

CMS-1500

A paper form used to submit professional claims for reimbursement with various payer groups

837I

The electronic UB-04 claim format (also known as the ANSI ASC X12N 837I) used to submit claims for facility services rendered by inpatient organizations.

UB-04

A paper form used to submit hospital and facility claims for reimbursement with various payer groups

Clearinghouse

provider submits claim to them so that they can “proofread” claim and make sure there are no errors. They convert forms to electronic flat file format, verify claims data & transmit to payers.

adjudication

process of determining financial responsibility among the stakeholders

Claims scrubbing/edit checks

efficient mechanism for proofreading claims

Medical record audit

process of comparing encounter notes to codes billed to make sure info matches.

Internal medical record audit

chart review to make sure documentation supports codes reported, identify improvement areas, & identify errors. AKA prepayment audits. Focuses on prevention of erroneous claim submission that could lead to external audit.

External medical record audit

AKA postpayment audit. These audits perform reviews to protect the payers and government programs from fraud and abuse. Third-party payers may conduct random or targeted audits.

Medicare Modernization Act of 2003

Created Recovery Audit Contractor (RAC) and Zone Program Integrity Contractor (ZPIC) programs.

RAC

Recovery Audit Contractor. Program that review fee-for-service claims and medical records on a postpayment basis. The goal is to identify and recover improper payments made to health care providers for Medicare patients. They collect on overpaid claims. Training for providers is also done.

ZPIC

Zone Program Integrity Contractor. Program that aims to combat fraud, waste, and abuse. Are TARGETED.

Deficit Reduction Act of 2005

Created Medicaid Integrity Contractor (MIC) program which reviews medicaid claims, performs audits, identifies overpmts, and educates providers about program’s integrity & quality of care for pts.

MFCU

Medicaid Fraud Control Unit. Investigates and prosecutes Medicaid provider fraud.

unbundling

using multiple CPT codes to report individual components of the documented procedure. Single code is available.

upcoding

reporting a higher-level service or procedure or a more severe diagnosis than is supported by the provider's documentation.

downcoding

occurs largely due to a lack of relevant or detailed information in the provider's documentation to assign a code for the optimal level of service, procedure, or diagnosis. Downcoding results in lower reimbursement and a loss of revenue for the organization.

Quality Payment Program (QPP)

This program shifts the focus from revenue-based care to value-based care. was created by the Medicare Access and CHIP Reauthorization Act (MACRA). Providers can choose the program details (MIPS or Advanced APMs) and the specific measures that best suit their organization. Organizations are scored on performance categories like quality and the use of certified EHR technology.

Merit-Based Incentive Payment System (MIPS)

organizations report quality measures (ex: >9% poor control of T2DM)

NUCC

National Uniform Claim Committee. provides guidelines for each block of the CMS-1500 form.

NUCC Claim Form

universal to all claims and payers

• Items 1-13: Patient & Insurance info

• Items 14-23: Physician/supplier info

• Section 24: itemized service charges

• Items 25-33: Physician/supplier info including TID, account No, charge, amt paid, signature

• DOB format: MMDDYYYY

• DOS format: MMDDYY

NCCI

National Correct Coding Initiative. This initiative provides a code editing system that prevents inappropriate reporting of CPT codes.

MUE

Medically unlikely edits. Feature of NCCI that is used to prevent overpmt of codes with unlikely unit value.

claims editing

A step in the claims process in which appropriate codes and rules are verified before the claim is submitted.

local coverage determination (LCD)

Describes coverage determined by a MAC about a particular service.

National Coverage Determination (NCD)

Describes Medicare coverage for a specific service procedure or device.

Delinquent claim

claims that are 30 to 45 days old, because the payer has removed the claim from the typical workflow. This type of claim requires follow up to determine the appropriate action. In some cases, the payer may investigate a claim or request additional information from the patient or health care organization.

Clerical Error Reopening (CER)

Medicare uses this correction process to correct minor errors/omissions on previously filed claim. Does not apply to rejected claims. Changes allowed: modifiers, place of service, dx codes, dos, procedure codes except for HCPCS J codes.

appeal

The official process of requesting a review of a claim that was underpaid or denied. Can be performed by phone, provider portal, or written submission. There are 5 levels of appeal process with instructions (not all levels required for each claim)

Medicare Administrative Coordinator (MAC)

A third-party payer that has been contracted to process Medicare Part A and Part B medical claims for Medicare Fee-For-Service (FFS) beneficiaries.

Redetermination

Filed with the Medicare Administrative Contractor (MAC) according to their instructions. Can be online or in writing.

Must be within 120 of the initial claims' determination.

Reconsideration

Filed with the qualified independent contractor (QIC) in writing.

Must be within 180 of the notice of redetermination.

Disposition by Office of Medicare Hearings and Appeals (OMHA)

Filed with HHS OMHA by telephone or video teleconference. In some cases, can be in person.

Must be within 60 days of the reconsideration decision. This level appeal can also be filed if the reconsideration time was missed.

Review by the Medicare Appeals Council (Council)

Filed with the council in writing.

Must be within 60 calendar days of the OMHA decision.

Judicial review in U.S. District Court

Filed in a district court according to the details provided by the Council's response.

Must be within 60 days of the Council's decision.

aging report

A report that shows the length of outstanding balances in the system. Ideally should have largest balances owed under 1-30 days and smaller balances in later date ranges.

payer mix

The showing of a percentage of usage under a specific payer. Basically percent of patients that are from each insurance.