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The Information Guidance for Savable New Cms 1500 Form

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Guide of Savable New Cms 1500 Form

welcome to this DME on-demand.presentation for the CMS 1500 claim form.the information given in this training.is correct as of October 2009 teen the.most current information related to this.topic can be found on the nuridium DME.website at the link listed on this slide.the CMS 1500 form is the form used to.bill Medicare on this form and to basic.information about the beneficiary as.well as the billing information for the.supplier it contains information on what.items or services are being billed as.well as the diagnosis to support the.billing the charges and the referring.provider it can either be filled out on.paper for those suppliers who meet the.asker requirements for a waiver or.electronically for all other suppliers.or physicians.this is what the CMS 1500 health.insurance claim form looks like nuridium.offers a tutorial with an interactive.form for detailed instructions on how to.complete it this is found under the.claims and appeals tab claims submission.and CMS 1500 claim form tutorial forms.can be obtained from printers or printed.in house as long as they follow the CMS.approved specifications it is the claim.form published by CMS for the Medicare.and Medicaid programs for use by.suppliers if a claim is submitted with.incomplete or invalid information it may.be returned to the submitter as.unprocess of all the back of the CMS.1500 form has the basic instructions on.completing the information also see.chapter 26 of the Medicare claims.processing manual.how does this supplier know if they are.using the correct version of the CMS.1500 form this number is located on the.right hand side of the form as shown on.this slide the current version is 0-2 -.1 - let's start filling out the CMS 1500.form by completing the top half which is.specific to the beneficiary and the.insurance coverage each field is titled.as an item let's start at the beginning.item 1 shows the type of insurance that.is applicable for the claim for Medicare.check the Medicare box in item 1 a enter.the beneficiary's insurance number for.Medicare this will be the number found.on the beneficiary's Medicare card in.item to enter the beneficiary's name be.sure to enter the beneficiary's name.exactly as it appears on their Medicare.card to ensure accurate processing do.not use nicknames or abbreviations as.this can delay processing or result in.an unnecessary denial and rework in item.5 enter the address and in item 3 enter.the date of birth and gender of the.beneficiary.for item 4 if there is insurance primary.to Medicare either through a.beneficiaries or spouse's employment or.any other source list the name of the.insured here when the insured and the.beneficiary are the same enter the words.same if Medicare is primary this field.is to be left blank.that brings us to item six in this field.check the appropriate box for the.beneficiary's relationship to the.insured when item four has been.completed if Medicare is the primary.insurance leave this item blank.if item four is completed then this.requires that item seven be completed as.well item seven will be the insurance.address and telephone number when this.is the same as the beneficiary enter.same.if the beneficiary wants Medicare.payment data forwarded to a medigap.insurer under a mandated Medigap.transfer the participating supplier must.accurately complete all of the.information in items nine nine a and.ninety a Medicare participating supplier.shall only enter the koba Medigap claim.based ID with in item nine d when.seeking to have the beneficiary's claim.crossed over to a Medigap ensure note.that item 9b and 9c are not required by.Medicare and will be left blank.in item 10 check yes or no by placing an.X in the center of the box to indicate.whether employment auto liability or.other accident involvement applies to.one or more of the services described in.item 24 enter the state postal code in.the place box any item checked yes.indicates that there may be other.insurance primary to Medicare identify.primary insurance information in item 11.item 11 must be completed as it is a.required field by completing this item.the supplier acknowledges having made a.good-faith effort to determine whether.Medicare is the primary or secondary.payer here enter the insurance policy or.group number if another insurance exists.primary to Medicare then continue to.complete 11a through C if no insurance.is primary to Medicare enter the word.none and proceed to item 12.some examples of insurance primary to.Medicare could be a group health plan.coverage which is working aged.disability and stage renal disease and.no fault or other liability and then we.have the work-related illness or injury.which includes workman's comp black lung.and veterans benefits.in item 12 the beneficiary or their.authorized representative must sign and.date the form unless the signature is on.file in lieu of signing the form the.beneficiary may sign a statement to be.retained on file in accordance with the.Medicare claims processing manual.chapter 1 general billing requirements.the authorization is effective.indefinitely unless the beneficiary or.the representative revokes this.arrangement the signature authorizes.release of medical information necessary.to process the claim it also authorizes.payment of benefits to the supplier of.service or supplier when the provider of.service or supplier accepts assignment.on the claim.and authorized signature is required for.Medigap if item nine has been completed.the beneficiary's signature or the.statement signature on file in this item.authorizes payment of medical benefits.to the physician or supplier.now that we have completed the.information and directly related to the.beneficiary and their insurance it is.time to complete the claim specific.information which is located on the.bottom half of the CMS 1500 form.items 14 16 18 and 23 must be completed.as applicable as they relate to the.beneficiary situation those fields that.do require a date can either be a six.digit or eight digit date leave items 15.20 and 22 blank as they are not required.when billing a DME claim.in item 17 the name of the ordering.physician will be entered starting with.the first name then last name no middle.initial and no credentials along with.the qualifier of DK this qualifier.should be entered in the field where the.green circle is shown on this slide just.prior to the referring provider field.item 17 a will be left blank in item 17.B the national provider identifier or.NPI of the physician will be entered all.physicians who order services or refer.Medicare beneficiaries must report this.data and should be provider enrollment.chain and order ship system or Pecos.enrolled.item 19 as the narrative field and is an.important field for the claim for.additional information here enter.additional information such as drug.names description information on a not.otherwise classified code additional.modifiers or additional information.needed for the processing of a claim.because this field has a limited number.of characters it is recommended to use.the common abbreviations listed on our.website the path can be found on this.slide in item 21 and to the patient's.diagnosis or condition to the highest.level of specificity for the date of.service enter the applicable.international classification of diseases.10th revision or icd-10 code indicator.as a single digit between the vertical.dotted line enter up to 12 diagnoses in.priority order note the change to the.new form as the diagnosis codes are now.listed as a through L this will be an.important distinction when entering the.diagnosis pointer on a claim line do not.insert a period in the icd-10 code.so far we have entered who the claim is.for who is being billed and the.diagnosis to justify the claim now let's.work on completing the elements to build.the equipment or supplies we do this on.items 24 a through J as shown on this.slide.item 24 a is the deed of service item 24.B is the place of service 24 C leaf.blank 24 D enter the applicable.healthcare common procedure coding.system or hick picks code without a.narrative description however when.reporting a not otherwise classified or.NOC code include a narrative description.in item 19 item 24 e is the diagnosis.code we reference that relates to the.date of service and services provided.enter only one reference number or.letter per line item this will be a.letter from a through L item 24 F is the.charge for the line item listed do not.use dollar signs decimals dashes commas.or lines item 24 G is the number of days.or units and item 24 H 24 I and 24 J are.to be left blank.item 25 is the provider or supplier.federal tax ID or employer.identification number.do not use hyphens or spaces item 26 is.the beneficiary's account number this.field is optional and is used to assist.provider in patient identification.note that if an account number is.entered in this item it will appear on.the provider's remittance advice item 27.is a required item and is used to.indicate whether or not the supplier.accepts assignment on this claim item 28.is for the total charge of the claim do.not mark as continued or the claim will.be rejected as unprocess about each CMS.1500 form should have its own total item.29 is the field to indicate the dollar.amount the beneficiary has paid on.covered services only again this must be.a total number with no decimal points do.not include the amount paid by the.primary insurance coinsurance.deductibles account balance or payments.on previous claims in this item if any.dollar amount is entered here part or.all of the payment will go directly to.the patient even for participating.providers it is important to understand.that in most cases an amount is not.entered in field 29 item 30 is not.required by Medicare and should be left.blank.item 31 is a required field and is the.signature of the provider or supplier as.well as the date the form was signed.note that the signature and date must be.completely within the confines of this.box this is a required field however the.claim can be processed if the following.is true if a physician supplier or.authorized person signature is missing.but the signature is on file or if any.authorization is attached to the claim.or if the signature field has signature.on file and/or a computer-generated.signature item 32 is where the name and.address of where the services were.rendered is entered this is only.completed with the address if the place.of service is anything other than home.or office in item 32 a enter the.national provider identifier of the.service facility in item 33 enter the.provider of service or suppliers billing.name address zip code and telephone.number this is also a required field.listed on this slide is the path to the.policies and articles on the nuridium.Medicare website and the CMS 1500 claim.form including a tutorial and form.instructions.thank you for taking the time to listen.to our tutorial continue your learning.experience by referring to additional.recordings available on the nuridium.website or youtube channel.

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