chapter 11 essential cms-1500 claim...
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© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.
CHAPTER 11 Essential CMS-1500 Claim Instructions
ASSIGNMENT 11.1 National Provider Identifier (NPI) Standard 1. a. The EFI is also known as the bulk enumeration. EFI is a process where a provider or group
canhaveanorganizationapplyfortheirNPI. b. The EFI process is designed to allow provider-designated organizations (the EFIOs) to capture
multipleproviders’NPIapplicationinformationonasingleelectronicfileforsubmissiontoNPPES.Toexplain,administrativesimplificationprovisionsofHIPAArequiredadoptionofastandard unique identifier for all health care providers for use in the nationwide health care system.TheNPIisthestandardidentifierprovidersbeganapplyingforNPIsin2005.SinceallHIPAA-coveredentities,includingMedicareandallotherhealthplans,mustreportNPIsinHIPAAstandardtransactions(includingelectronicclaims),providersmustobtainNPIspromptly so they can use them in these transactions and not experience interruptions or delaysinreceivingreimbursementfromahealthplan.AprovidercancurrentlyobtainanNPIviaapaperapplicationoroverthewebthroughtheNationalPlanandProviderEnumerationSystem(NPPES).Applicationsmustbesubmittedindividually,onaper-providerbasis.
2. a.TheNationalProviderIdentifier(NPI)isaHealthInsurancePortabilityandAccountability Act(HIPAA)AdministrativeSimplificationStandard.TheNPIisaunique(10-character)
identification number for covered health care providers.
b. Covered health care providers and all health plans and health care clearinghouses must usetheNPIsintheadministrativeandfinancialtransactionsadoptedunderHIPAA.
ASSIGNMENT 11.2 Medically unlikely Edits (MuE) Project 1.CMSdevelopedmedicallyunlikelyedits(MUEs)toreducethepaidclaimserrorrateforPartB
claims.
2.AnMUEforaHCPCS/CPTcodeisthemaximumunitsofservicethataproviderwouldreportunder most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codesdonothaveanMUE.
3. TheMUEwasimplementedJanuary1,2007,andisutilizedtoadjudicateclaimsatCarriers,FiscalIntermediaries,andDMEMACs.
4. Inquiries about a specific claim should be addressed to the claims processing contractor.
5.InquiriesabouttherationaleforanMUEvalueshouldbeaddressedtoyourclaims processing contractor or a national health care organization whose members often perform
the procedure.
ChApTEr 11: Essential CMS-1500 Claim Instructions 165
NOTE: ThepurposeoftheNationalProviderIdentifier(NPI)istouniquelyidentifyahealthcareproviderinstandardtransactions,suchashealthcareclaims.NPIsmayalsobeusedtoidentifyhealthcareprovidersonprescriptions,ininternalfilestolinkproprietaryprovideridentifi-cationnumbersandotherinformation,incoordinationofbenefitsbetweenhealthplans,inpatientmedicalrecordsystems,inprogramintegrityfiles,andinotherways.
NOTE: HIPAArequiresthatcoveredentities(e.g.,healthplans,healthcareclearinghouses,andthosehealthcareproviderswhotransmitanyhealthinformationinelectronicforminconnectionwithatransactionforwhichtheSecretaryofHealthandHumanServiceshasadoptedastandard)useNPIsinstandardtransactionsbythecompliancedates.ThecompliancedateforallcoveredentitiesexceptsmallhealthplanswasMay23,2007;thecompliancedateforsmallhealthplanswasMay23,2008.Asofthecompliancedates,theNPIistheonlyhealthcareprovideridentifierthatcanbeusedforidentificationpurposesinstandardtransactionsbycoveredentities.
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166 SECTION V: Answer Keys to Workbook Chapter Assignments
ASSIGNMENT 11.3 Identifying CMS-1500 Claims Completion Errors
X 123456798
CHRIS P. CREAM 09 08 60 X CREAM, CHRIS, P
8890 ECLAIR LANE
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X 8880 ECLAIR LANE
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09 08 1960 X
AETNA
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SIGNATURE ON FILE SIGNATURE ON FILE
07 04 YYYY 431
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DONALD L GIVINGS MD MMDDYYYY
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© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.
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ChApTEr 11: Essential CMS-1500 Claim Instructions 167
X 42915750
BRIGHT, BRITTANY 04 07 1988 X WRIGHT, BRITTANY
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X 8731 NOVELS AVENUE
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Ceng
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Lear
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© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.
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168 SECTION V: Answer Keys to Workbook Chapter Assignments
Cour
tesy
of t
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ente
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© 2
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Ceng
age
Lear
ning
®.
© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.
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ChApTEr 11: Essential CMS-1500 Claim Instructions 169
© 2017 Cengage Learning®. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.Current Procedural Terminology © 2015 American Medical Association. All Rights Reserved.
ASSIGNMENT 11.4 Multiple Choice Review 1. d 9. d 2. b 10. b 3. c 11. c 4. b 12. b 5. b 13. c 6. b 14. d 7. d 15. b 8. a
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