The upper portion of the CMS-1500 claim form (Item Numbers 1–13) lists demographic information about the patient and specific information about the patient’s insurance coverage.
The lower portion of the CMS-1500 claim form (Item Numbers 14–33) contains information about the provider or supplier and the patient’s condition, including the diagnoses, procedures, and charges.
The information needed to complete claims is gathered from the practice management program’s databases. First, data about the patient, guarantor (subscriber), insurance coverage, and demographics are entered based on the patient information form, insurance card, and payer verification data. After the patient’s visit, the transactions—the charges and payments—are entered as detailed on the encounter form. The PMP combines the elements from its relevant databases and prepares the claim that has been specified, either the HIPAA claim (837) or a paper claim (CMS-1500 08/05). Any missing elements and information are added during the claim editing process.
Required data elements must be provided on the claim and accepted by a payer; situational elements must be provided under certain conditions.
The HIPAA 837 claim transaction has five major sections: (a) provider, (b) subscriber/patient, (c) payer, (d) claim information, and (e) services. Most of the information from the practice management program that is gathered for CMS- 1500 claims is included on the HIPAA 83. Additional data elements include claim filing indicator code, individual relationship code, claim control number, claim submission reason code, and line item control number.
The billing provider is the entity that is transmitting the claim to the payer, usually a billing service or a clearinghouse. The pay-to provider receives the payment from the insurance carrier. A rendering provider is a physician who provides the patient’s treatment but is not the pay-to provider. A referring/ordering provider has sent the patient for treatment.
A claim control number is a unique number given to each claim to track the claim’s payments. A line item control number is another unique number assigned to each service line. Like the claim control number, it is used to track payments from the insurance carrier, but for a particular service rather than for the entire claim.
Clearinghouses, which are business associates of covered entities under HIPAA and must therefore adhere to proper practices for privacy and security of PHI, help providers and payers communicate using HIPAA transactions. They take nonstandard EDI communications and convert them to HIPAA-standard communications.
Claim attachments may be electronic or paper. A claim attachment number is assigned, and the type of attachment is reported with a code. Patient credit–debit information for future payment of the amount due after the carrier pays can also be reported using the health care claim transaction.
Three methods for claim transmittal are (a) direct transmission, in which the claim is sent by EDI directly to the payer’s computer system, (b) via a clearinghouse that transmits the data file to the payer in correct format, and (c) direct data entry, in which the provider keys data elements directly into the payer’s computer system, rather than transmitting them via EDI.
