The Process of Submitting The CMS-1500 Claim Form Through a Third-party Administrator

The Process of Submitting The CMS-1500 Claim Form Through a Third-party Administrator

Insurance claims are prepared by medical assistants using a computer billing or submitting information about the claim to an insurance billing clearinghouse. Hicks (2017) argues that insurance forms have changed over the years, particularly due to the implementation of the electric transfers of claims hence increasing accuracy in the filling and reimbursement of claims. The National Uniform Claim Committee designs and maintains the CMS-1500. Individuals making an insurance claim are required to purchase the claim forms and should contact the United States Government Printing Office, local printing companies in their area, or office supply stores. The form is used by professional providers, physicians, and suppliers that accept Medicare insurance. The form is used as a standard claim by non-institutional providers and to submit charges for outpatient and physician services. The information on the form is part of the claims for claims in part Medicare services (Kander, 2009). The form is also used to report claims for inpatient and outpatient services by ambulatory surgery centres and hospitals. The type of information required to complete the form is insurance identification number, patient’s sex, date of birth, name and address, other insured’s name, address, insurance plan, hospitalization dates related to the current service, diagnosis of injury or illness, outside lab charges, services or procedures that were used, CMS service code, qualifier code, diagnosis codes and the physician supplier’s billing address and name (Kander, 2009). It is important to refer to and be sure about any local rules that insurance companies may have in relation to the filling of the form.HIPPA provides that claims should be made electronically. Ambulatory services, physician offices, and other outpatient facilities use the CTP code as a representation of the procedure performed. Physician claims are then submitted on the CMS-1500 form, which is a procedure performed by professional healthcare providers and physicians. Individuals are required to provide the correct information to ensure that the claim is processed without delays while being considerate of any local rules that insurance companies may have.

There are two primary types of medical reimbursements: the fee-for-service method and the episode-of-care reimbursement method. The fee-for-service method is used when healthcare providers, such as hospitals, reimburse a claim for their fee to the insurer on an individual’s behalf. This method provides maximum freedom and flexibility to the individuals, thus enabling them to fully control their health decisions. It may incorporate Exclusive Provider Organization, Point of Service, Preferred Provider Organization, and Health Maintenance Organization. Exclusive Provider Organization is a managed care plan where the services are only covered if an individual uses hospitals, specialists, or doctors in the plan’s network except when there is an emergency. Preferred Provider Organization is a type of health plan where an individual pays less if an individual uses providers in the plan’s network. An individual can use hospitals, doctors, and providers outside the network without a referral for an extra cost. A Health Maintenance Organization is a type of health insurance plan that often limits coverage to care from doctors working for or contracting with the HMO. It does not cover out-of-network care except in an emergency. A Health Maintenance Organization may require an individual to work or live in its service area to be eligible for coverage. It usually provides integrated care and focuses on wellness and prevention. Point of Service is a type of plan where individuals pay less if they use hospitals, doctors, and other healthcare providers belonging to the plan’s network. It requires an individual to get a referral from their primary care doctor to see a specialist. In episode-of-care reimbursement, the providers, including physicians and hospitals, receive a lump sum for all the services relating to a specific condition or disease, thus eliminating the need to reimburse individual charges and control the total cost of healthcare.

A third-party administrator is used to process an insurance claim. A third-party administrator is a company that offers operational services such as claims processing and the management of employee benefits under contract to another company. Self-insured companies and other insured companies usually outsource the processing of claims to third parties. The use of third-party administrators is common in many businesses, and the number of tasks they complete is increasing (Blokdyk, 2018). They have unique roles in the health insurance sector, investment companies, and health insurance industry operations. Some organizations are venturing into new areas, such as worker’s compensation audits, forensic accounting services, and emergency response planning. Third-party claims administrators are mainly used by health insurance providers who outsource most of their administrative functions. A health provider or hospital that sets up its health plan usually outsources the administrative responsibilities to a third party. A company that chooses to self-fund the health insurance plan of its employees often contracts with a third-party claims administrator to run the program. The administrators may manage employee retirement programs (Blokdyk, 2018). In such instances, the company is usually managed or owned by the investment company, which handles the management of funds, while the third-party administrator deals with the day-to-day customer care and account operations functions.

References

Blokdyk, G. (2018). Third-party administrator a complete guide – 2019 edition. 5starcooks.

Hicks, J. (2017). CMS 1500 Claim Form. Retrieved from

https://www.verywell.com/changes-to-the-cms-1500-form-2317062

Kander, M. (2009). The CMS-1500 claim form. The ASHA Leader, 14(7), 3-7. https://doi.org/10.1044/

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Introduction:
While the CMS-1500 claim form may not be used for private-pay patients, it will be required for all claims when the patient is covered by any form of insurance to recover payment for services. Working knowledge of the CMS-1500 is essential for all persons working in healthcare’s revenue and billing area.

Tasks:
Using the CMS-1500 form, fill out the form for a non-Hodgkin’s lymphoma (page 183) and a radiological Oncology treatment (page 278). For assistance with completing and saving a PDF document, please click here.
Use patient information on EOB Figure 4-17 of text (page 90).
Describe the process of submitting this claim form through a third-party administrator.