The CMS-1500 claim form is used to submit non-institutional claims for health care services provided by physicians, other providers and suppliers to Medicare. It is also used for submitting claims to many private payers and Medicaid programs, as well as other government health insurance programs. Most institution-based services claims are submitted using a UB-04 form. Provider agreements and billing guidelines provide additional instruction for claims completion. If you wish to explore outsourcing claims and billing see factors to consider when selecting a professional billing service. Show
Before You Submit A ClaimPayment of claims for MNT provided in the outpatient environment is dependent on several factors, including an individual's benefits for MNT for their condition or reason (e.g., prevention), approved settings, and the network status of the RDN (or practice) with the client/patient's payer. Claims can be submitted to payers electronically through many vehicles, including practice management systems, provider portals, and claims clearinghouses. There may be some instances where paper claims are still used. Completing a CMS 1500 Claim FormSpecific client and provider information must be provided on a CMS 1500 health insurance claim form for a payer to process a claim regardless of how it is submitted. Some payers may require additional information or require the completion of specific fields in certain situations (e.g., group number, prior authorization reference number, workers compensation). The information provided here to assist RDNs in the process of completing a claim form is general. Refer to each payer's billing instructions for more information or contact a Provider Services representative of the health plan to understand options for submitting claims. Refer to the following sample completed claim and quick reference to assist you in completing a CMS 1500.
Secondary Insurance with Medicare beneficiaries and the use of Modifiers in ClaimsSome Medicare beneficiaries have secondary insurance policies (e.g., commercial insurance through work or a partner's policy) that provide benefits and coverage for conditions beyond the standard Medicare Part B MNT benefit (e.g., DM, CKD and 3 years post kidney transplant). The secondary payer may require evidence of a denied claim from the primary insurance (Medicare) before it will pay the claim (e.g., MNT for a gastroenterological or other diagnosis). A claim is submitted to Medicare that must include a modifier (GA, GZ or GY) to generate a denial required before the secondary insurance will review the claim. For more information, including descriptions and use of each modifier, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market or to page 8 of the CMS Manual. Electronic ClaimsWhen completing claims electronically (e.g., use of a clearinghouse) you will also select a payer ID, a unique code for each payer. Some payers may require providers to complete an agreement before they will accept electronic claims through a third-party service such as a claims clearinghouse. Otherwise, claims clearinghouses allow you to select participating payers from a menu. Medicare electronic claims transactions must meet Electronic Data Interchange requirements. RDN Medicare providers can submit claims using applications that meet Medicare's EDI requirements. Providers must complete an EDI enrollment agreement. Registered dietitian nutritionists are able to submit claims electronically to a Medicare Administrative Contractor (MAC). Registered dietitian nutritionists should contact their MACs for more information. For more comprehensive instructions regarding claims submission, refer to the RDNs Complete Guide to Credentialing and Billing: The Private Payer Market. Additional ResourcesCMS-1500 Paper Claim FormThe form specifications require red drop out ink in order to facilitate the use of image processing technology such as Image Character Recognition (ICR), facsimile transmission and image storage. It is available in various formats (e.g., single copy, duplicate, etc.). The CMS-1500 claim form may be purchased from local printers, office supply stores, or through the U.S. Government Printing Office: U.S. Government Printing Office Superintendent of Documents Washington, DC 20402 Pricing Desk: 202/512-1800 or 866/512-1800 Fax: 202/512-2104 Email: bookstore.gpo.gov
For healthcare professionals and medical billing companies, having a complete understanding on CMS 1500 & UB-04 forms, are extremely necessary to make their billing practice successful. These forms are designed and maintained by National Uniform Claim Committee (NUCC). CMS 1500 & UB-04 are used especially for revenue payments, and they vary in terms of usage. Before filing a claim, it’s important to know which form to use in order to get proper reimbursement. CMS-1500 & UB-04 are the most common claim forms submitted to the insurance companies. Though they are very frequently used, both have their own specifications that allows medical billing process to run without any confusion. Let’s get into the details to learn more about CMS 1500 & UB-04 forms. What are CMS 1500 & UB-04 Forms?CMS 1500:
UB-04:
What are the differences between CMS 1500 & UB-04 Forms?
Structure of CMS 1500 & UB-04 claim forms:
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