Question

Describe the process of submitting a CMS-1500 form though a third party administrator.

Answer 1

A health claim that is reviewed by a third party payer to bill Medicare-fee-for-service contractors. It is used to bill various government and private insurers. The paper form has 8.5 x 11 inches in size. The front side is OCR scannable and the backside contains instructions of the health sector. the top portion consists of patient information and the bottom portion has physician and supplier information.

OCR scanning convert character image into code based on the American standard code for Information Interchange. Then it is scanned and printed in red ink. CMS-1500 forms should be complete with specific guidelines such as

• Use Times New Roman with font size 12 and black text used.
• Use only Capital letters.
• The punctuation to be avoided.
• Use the format of MM DD YYYY.
• For procedure modifier code use dash.
• Hyphens in employment identification number.
• Do not use signatures on the form.
• Do not staple the form.

CMS-1500 can also be submitted through electronically which reduces the expenses. But the major drawbacks are claim process requires approval from the state and the federal government. The whole process will take 6 - 7 weeks. The five documents should be attached while submitting the claim form which includes

• The patient information form that provides the data on demographic and insurance information.
• The patient's insurance ID card that contains a number.
• The patient's health record which gives information on patient's visit, physician order.
• The encounter form of ICD -9 codes and CPT of the services provided.
• The patient ledger card consists of the fees charged for services.

Proofreading is essential before submission to avoid rejection. A clearinghouse which checks the accuracy and validity of the multiple claims and edits it, if needed for proper payment. If it is a single carrier then the direct submission is the best choice.