Chapter 5 - Lesson 12, 13

Completing Two Common Insurance Forms

The software that you have been provided is a full working version of the billing software that we recommend. It is capable of being connected to the Electroniclaim Clearinghouse. Also included is a CD video training program that will provide further detailed training on the program itself and allow you to be proficient enough to process claims electronically. If required, further training can be purchased, including a two- day seminar explaining in depth the complete software program.

It is apparent that the industry is transitioning to a strictly electronic submissions system, and many insurance companies are now making it mandatory to file claims electronically. However, there are still many claims that must be filed with the HCFA-1500 form with backup documentation for the claim. The information that follows will assist you with non-electronic claim submissions.

The following information has been provided in order to familiarize you with the most common insurance claim, the HCFA-1500.

Step 1: Read this Lesson Preview

As you have worked your way though this course, you have learned nearly all of the "basics" for filing insurance claims. You have probably noticed that claim forms have been referred to frequently. You may have asked a few times, "When will I be able to complete one of these forms?" This lesson is providing you with an opportunity to do just that. In this lesson, you will learn, line by line, how to complete the most common claim form, the HCFA-1500. (See the enclosed example of the HCFA-1500 form.)

The HCFA-1500 health insurance claim form is used throughout the health care industry. Private insurance companies, such as Medicare, Medicaid, and other coverage providers use this form. Some state programs may use a slightly different form due to the equipment they use to read the claims. These forms, however, are designed to be as close to the HCFA-1500 as possible.

Because of its widespread use, the HCFA-1500 form contains spaces for a wide variety of information. Each space is numbered sequentially. These numbered spaces are called fields. When explaining how to complete the form, we will refer to these fields by their numbers. For example, on the HCFA-1500 form, the space for the patient's name is referred to as Field 2.

As you look at the sample HCFA-1500 form, you will see arrows on the right edge of the form and type on the sides of each field. The arrows divide the form into three sections: CARRIER, PATIENT AND INSURED INFORMATION, and PHYSICIAN OR SUPPLIER INFORMATION.

Carrier Section

Type the name and address of the insurance carrier in the space above the words HEALTH INSURANCE CLAIM FORM on the top right side of the claim form.

PATIENT AND INSURED INFORMATION SECTION, FIELDS 1-13

Field 1: Program Designation

This field contains seven boxes. The boxes are labeled Medicare, Medicaid, CHAMPUS, CHAMPVA, Group Health Plan, FECA Black Lung and Other. You must type an X in the box that best describes the patient's coverage plan for this claim.

Field 1a: Insured’s ID Number

Type the insured's identification number in this field. This identification number can be found on the insurance identification card issued by most carriers. Follow the guidelines shown here to choose the appropriate number.

Insurance Program Guidelines

Medicare. Even if Medicare is the secondary carrier, you must still type the patient's Medicare identification number in this box and input the primary carrier identification number in Field 11.

CHAMPUS/CHAMPVA. Use the sponsor's social security number.

Private Health Insurance Carrier. Use the patient's identification number.

FECA. Use the patient's social security number.

Field 2: Patient's Name

Input the patient's name; last name first, first name last. Do not use nicknames or abbreviations.

Field 3: Patient's Date of Birth and Sex

Input the patient's date of birth using numbers. This field is divided into four sections, labeled MM, DD, YY and SEX. Example: If Mike Piazza was born on March 23, 1966, you will input his date of birth as: 03-23-66. Input an X in the appropriate box to indicate the patient's sex.

Field 4: Insured's Name

Input the name of the person who is insured on the primary policy. Input the name in the following order: last name, first name. This format is important. The insured's middle name or initials may be placed after the first name at the end of the field. In many cases, the patient is covered under a policy held by someone else. If the insured and the patient are the same person, type the word SAME in this field.

Field 5: Patient's Address

Input the patient's permanent address on the lines indicated. Place the street address on the first line and the patient's city and state on the second line. When abbreviating the name of the state, use the official post office abbreviation. Input the patient's zip code on the third line. Be sure to include the area code when inputting the telephone number.

Field 6: Patient Relationship to Insured

This field contains four boxes. The boxes are labeled Self, Spouse, Child and Other. Input an X in the box showing the correct relationship between the patient and the insured as shown in Field 4. For example, if John Redlin is the insured and his son, Charles, is the patient, then you must input an X in the box marked Child to indicate the that patient is a child of the insured.

Field 7: Insured's Address

Input the insured's permanent address on the lines indicated. Be sure to put the street address on the first line, the insured's city and state on the second line and the insured's zip code and telephone number on the third line. When typing the telephone number, be sure to include the area code; when you abbreviate the name of the state, use the official post office abbreviation. If the insured's address is the same as that of the patient, input the word SAME in this field. Review the guidelines that follow.

Insurance Program Guidelines

Medicaid and FECA. If the patient and the insured are the same person, leave Field 7 blank, unless you completed Fields 9 or 11.

CHAMPUS and CHAMPVA. When the sponsor is on active duty, type the sponsor's full duty station address. If the sponsor is stationed overseas, type APO or FPO address.

Field 8: Patient Status

This field contains six boxes. The first three boxes are labeled Single, Married and Other. Input an X in the box that correctly identifies the patient's marital status. The last three boxes are labeled Employed, Full-Time Student and Part-Time Student. Input an X in the box that correctly identifies the patient as employed or as a student. If the patient is neither employed nor a student, leave the field blank.

Field 9: Other Insured's Name

If there is no secondary insurance, type NONE in this field. If the insured is the patient, type SAME in the field. If the patient is covered by secondary insurance, type the name of the person who is insured on the secondary policy. Input the name in the following order: last name and then first name. This format is important. The insured's middle name or initials can be placed after the first name at the end of the field. Do not use nicknames or abbreviations.

Field 9a: Other Insured's Policy or Group Number

Input the insured's policy or group number of the other insurance in this field. Look at these guidelines.

Insurance Program Guidelines

Medicare. If the secondary policy is a Medigap policy, input MEDIGAP and the policy number in Field 9a. If the Medicare patient has supplemental coverage through a former employers group health plan, input "Employer - SUPP" and the patient's ID number in Field 9a.

Medicaid. If the patient is covered by Medicaid, input "Medicaid" and the patient's ID number in Field 9a.

Field 9b. Other Insured's Date of Birth and Sex

Input the other insured's date of birth using numbers. The field is divided into 4 sections, labeled MM, DD, YY and SEX. Enter as you would in Field 3.

Field 9c. Employers Name or School Name

Input the name of the other insured's employer or school in this field.

Field 9d. Insurance Plan Name or Program Name

Input the name of the other insured's plan or program in this field using the following guidelines:

Insurance Program Guidelines

Medicare or CHAMPUS. Input the words Medicare or CHAMPUS in Field 9d. Also input the word ATTACHMENT in field 10d. Attach a separate sheet of paper with a complete address for the plan's claim processor.

CHAMPUS. If the patient's policy is an HMO, type the word ATTACHMENT in field 10d. Attach a copy of the HMO brochure showing the services on the plan are not covered by the HMO.

Field 10. Is Patients Condition Related To:

This field contains 6 boxes divided into 3 sections: 10a, 10b and 10c.

Field 10a. Employment (Current or Previous)

Input X in the" yes" box, if the patient's condition is employment related. Input an X in the "no" box if the patient's condition is not employment related.

Field 10b. Auto Accident and Place?

Input X in the "yes" box if the patient's condition is the result of an auto accident. Input the state abbreviation in the next line after the word "state." Input an X in the "no" box if the patient's condition is not a result of an auto accident.

Field 10c. Other Accident

Input an X in the "yes" box if the patient's condition is the result of another accident. Input an X in the "no" box if the patients condition is not the result of another accident.

Field 10d. Reserved for Local Use

If this is a Medicare claim, this box must contain the code for the secondary coverage.

Field 11. Insured's Policy Group or FECA Number

Input the insured's policy or group number in this field.

Insurance Program Guidelines

FECA. Input the patient's FECA number in Field 11.

CHAMPUS. If the patient is covered by additional insurance, input the

policy or group ID number in Field 11.

Field 11a. Insured's Date of Birth and Sex

Input the insured's date of birth as shown in Field 3.

Field 11b. Employer's Name or School Name

Input the name of the insured's employer name or school name in this field.

Field 11c. Insurance Plan Name or Program Name

Input the name of the insurance carrier or government insurance program.

Be sure to indicate the state or geographic area for Blue Cross and Blue Shield claims. (Example: Blue Cross and Blue Shield of Colorado).

Field 11d. Is There Another Health Benefit Plan?

Input an X in the yes box if the patient has secondary coverage on this claim. Input the appropriate information in Fields 9-9d if you type an X in the "yes" box. Input an X in the "no" box if the patient does not have secondary coverage on this claim.

Field 12. Patients or Authorized Person's Signature

In order to release confidential information to anyone, you must have permission from the patient or the person authorized to give consent for the patient. The most common entry for this field is SIGNATURE ON FILE in which you certify to having an authorized signature on file in the patient's chart. Also you should fill in the date the form is signed.

Field 13. Insured's or Authorized Person's Signature

By signing in this field, the insured (or authorized person) gives the insurance carrier permission to pay medical benefits directly to the physician. If this is the situation, type "Signature on File." Leave this field blank if the office accepts payment from the patient at the time of service. Leave blank for all other government policies.

Insurance Program Guidelines

Medicare. Leave Field 13 blank because Medicare patients automatically authorize payment of medical benefits when they sign Field 12. If the Medicare patient has Medigap, Field 13 should be filled in with "Signature on File" for the supplemental insurance carrier to pay benefits directly to the physician.

CHAMPUS. Leave Field 13 blank because these patients automatically authorize payment of medical benefits when they sign Field 12.

This is the end of the PATIENT AND INSURED INFORMATION section of the HCFA-1500 form.

Completing the HCFA-1500 Form

HCFA - 1500 Fields 14-33. Physician or Supplier Information

Field 14. Date of Current Illness, Injury, Pregnancy

Input in the date as done in Field 3. For an illness, input in the date the first symptoms appeared or "Unknown" if this information is not known. For an injury, input in the date the accidental injury occurred. For pregnancy, type in the date of the last menstrual period (LMP).

Field 15. If the Patient has had Same or Similar Illness, Give First Date.

If this is the same or similar condition as a previous claim, input the first date of occurrence. Input in the date using numbers (as in field 3).

Insurance Program Guidelines

Medicare. Leave Field 15 blank for Medicare patients.

Field 16. Dates Patient Unable to Work in Current Occupation

This field is divided into two sections: FROM and TO. Input the beginning date and ending date the patient was unable to work at his/her current position. Input in the date using numbers (as in Field 3).

Field 17. Name of Referring Physician or Other Source

Input the name of the referring physician or other source in this field. If there is no referring physician or other source, leave Field 17 blank.

Insurance Program Guidelines

CHAMPUS. If the patient is referred by a military treatment facility for treatment at a civilian health facility, input the name of the facility in Field 17 and attach a DD Form 2161 (Referral for Civilian Medical Care form).

Field 17a. ID Number of Referring Physician

Input the referring physician's federal tax ID number in this field.

Insurance Program Guidelines

Medicare. In Field 17a, input the attending Medicare physician's PIN assigned by the Health Care Finance Administration.

Field 18. Hospitalization Dates Related to Current Services

This field is divided into two sections: FROM and TO. Input the beginning date and ending date the patient was hospitalized. Input the date as inputted in Field 3.

Field 19. Reserved for Local Use

This field is used to relate special instructions from an insurance carrier or government program.

Field 20. Outside Lab Charges

This field contains two sections. If laboratory work was performed by a lab other than the physician's office, type an X in the "yes" box and fill in the amount the laboratory charged under the $CHARGES heading. If there were no lab services performed, input an X in the "no" box.

Insurance Program Guidelines

Medicare. Only clinical lab services performed by the physician's office can be billed on the claim. Outside labs must file their own Medicare claim for services performed.

Field 21. Diagnosis or Nature of Illness or Injury

Input the complete diagnosis code, including any applicable modifiers.

Remember to type the primary diagnosis first, then any other diagnosis. You should type a diagnosis code for any condition that is treated. Do not include a diagnosis code for services performed at no charge.

Field 22. Medicaid Resubmission Code and Original Reference Number

Type in the Medical Resubmission Code Assigned to the claim by Medicaid and the Original Reference Number of the claim.

Field 23. Prior Authorization Number

Input the prior authorization number for the claim, if one exists.

Field 24. Transaction Entry

This field contains eleven boxes, 24A-24K.

Field 24A. Date(s) of Service

This field is divided into two sections: FROM and TO. Input the beginning date (the first day services are performed) and ending date (the last day services are performed). Input the date using numbers. (See Field 3.)

Field 24B. Place of Service

In this field type the 2 digit code for place of service. Many insurance carriers use similar codes. Place of service codes are included in instructions for filing government program claims as well as private insurance carriers. Often these codes are on the back of the insurance claim form provided by the carrier. The following is a list of place of service codes used most often:

Field 24C. Type of Service

Insurance Program Guidelines

Medicare. Leave Field 24C blank.

Field 24D. Procedures, Services or Supplies

This field is divided into 2 sections: CPT/HCPCS and MODIFIER. Input the procedure codes for the services performed and add an appropriate modifier to the procedure code when necessary. Remember, use CPT codes with CPT modifiers and HCPCS codes with HCPCS modifiers.

Insurance Program Guidelines

Medicare. HCPCS codes are used for some services for Medicare patients.

Field 24E. Diagnostic Code

This field designate which service was performed for the diagnosis you entered in Field 21. Look back at Field 21 and notice that each line is numbered. Now writer the number that is beside the diagnostic code next to the procedure performed. For example, if you have inputted the diagnostic code 382.9 for otitis media on line 1 of Field 21, then type a 1 in Field 24E next to the procedure code 99212 for a limited office visit performed for the diagnosis.

Field 24F. Charges

Field 24G. Days or Units

This field shows the number of days or units involved. For example, if the charge is for five hospital days, type a range of five days in Field 24A and type a 5 in Field 24G. Then multiply the standard charge by five.

Field 24H. EPSDT Family Plan

This field is used only when the patient receives medical services paid for under the EPSDT (Early and Periodic Screening, Diagnostic and Treatment). If the patient and the medical services are covered by EPSDT, type an X in Field 24H.

Insurance Program Guidelines

Medicare and CHAMPUS. Leave Field 24H blank.

Field 24I. EMG

If the medical service was performed in a hospital emergency room, type

an X in the field. If this field is checked, be sure you typed the correct 2 digit Hospital Emergency Room place of service code. Otherwise, leave blank.

Insurance Program Guidelines

Medicare and CHAMPUS. Leave Field 24I blank.

Field 24J. COB

Leave this field blank.

Field 24K. Reserved for Local Use

This is for Medicare and Medicaid. If the attending provider is not the assigned provider physician identified in Field 33, input the name and PIN of the provider in this field. This is to identify and record additional providers within the same practice who are treating the same patient.

Field 25. Federal Tax ID Number

This field contains three sections. If the claim is for a group practice, type the federal tax ID number, type the number and type an X in the EIN (employer identification number) box.

Field 26. Patient Account No.

Type the patient's account number, as assigned by the physician.

Insurance Program Guidelines

Medicare. The patient's account number is required for all electronically filed claims.

Field 27. Accept Assignment?

If the claim is for a government program and the physician is a participating provider and accepts assignment for the claim, type an X in the "yes" box. If the physician is not a participating provider, type an X in the "no" box.

Insurance Program Guidelines

Medicare. You must type an X in the "yes" box in Field 27.

Field 28. Total Charge

Type the total amount of all charges entered in Field 24F.

Field 29. Amount Paid

Input the total amount paid by the patient on the claim. Include only payment for medical services listed on the claim form. Do not include any other payments.

Insurance Program Guidelines

CHAMPUS. In Field 29, do not enter payments paid by the patient. Type only amounts received from other government programs or insurance plans.

Field 30. Balance Due

Subtract the amount in Field 29 for the amount of any money paid from

Field 28 for the total charges. Type the remainder in this field. Remember, use only amounts shown on this particular claim form and for the medical service it lists.

Field 31. Signature of Physician or Supplier Including Degrees of Credentials

Have the physician sign the form in this field and enter the date the claim form is signed. The signature must include the degrees or credentials held by the physician. Some insurance carriers require an actual signature. Others will accept a stamped copy.

Field 32. Name and Address of Facility Where Services Were Rendered

If the address where the services were performed is different from the address shown in Field 33, then fill in this field with the appropriate address where services were rendered.

Insurance Program Guidelines

CHAMPUS. In Field 32 input the address and the telephone number (including area code) of the facility where services were performed.

Field 33. Physician's, Supplier's Billing Name, Address, Zip Code and Phone #

Input the name of the physician or group, and the complete address and telephone number (including area code). If the claim is for a group practice, type the GRP# (group practice number). For a single practitioner, input the PIN.

This the end of the PHYSICIAN OR SUPPLIER INFORMATION section of the HCFA-1500 form.

Proofreading and Processing the HCFA-1500 Form

Proofread the claim form to ensure accuracy and prompt payment from the

carrier. Pay close attention to these fields:

1.Patient's name 2.Patient's birth date

11 Insured's policy group number

12 Authorized signature

21 Diagnosis code

24E Procedure code

24F Charges

31 Physician's signature

2. Photocopy the form and place a copy of the form in a pending file.

3. Type the date, patient's name and the insurance carrier in an insurance log. You will use this log when researching information for insurance carrier questions, denied claims, second billing and client questions.

4. Type the date and the words insurance filed on the patient's ledger

card after the last entry for the services billed on the insurance claim form.

5. Before you submit the insurance claim form to the insurance carrier, double-check these fields for accuracy:

6. Always keep a copy of the HCFA-1500 form for your records.

7. Submit the insurance claim form to the insurance carrier for payment.

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