Billing Each Payer Correctly in Medical Billing and Coding

By Karen Smiley

Most payers accept electronic claims, although some still require paper claims. It’s your responsibility to know which method will be accepted. This information is contained in the payer contract, but sometimes you need to call and ask how to submit the claim.

You’ll encounter various formats or platforms of electronic claim submissions. For that reason, as the biller, you also need to make sure that the correct format is linked to each individual payer. Fortunately, this information isn’t too difficult to find: The patient’s insurance card normally has claim submission information on it, and of course, you can always call the payer to check prior to submitting a claim if you have any uncertainty.

Medical billing and coding is going paperless. Remember those giant sliding file cabinets in the doctor’s office? They’re either gone or are being used to store the office holiday decorations. The Health Insurance Portability and Accountability Act (HIPAA) now makes it necessary to bill most claims electronically.

For several decades, medical billing was entirely on paper. Then medical practice management software was developed and made claim processing more efficient. Although paper claims may soon be extinct due to the introduction of the HIPAA, certain payers are exempt and will continue to accept and possibly require paper claims.

The CMS‐1500 form

The Centers for Medicare & Medicaid 1500 (CMS‐1500) form, formerly known as a Health Care Financing Administration‐1500 (HCFA‐1500) form, is the paper form used to submit claims for professional services. Physicians and clinical practitioners submit their claims on this form, which is printed in red ink and contains spaces for all the necessary information. Directions for completing the form are printed on the back of each one.

The HCFA/CMS‐1500 form.

The HCFA/CMS‐1500 form.

Various forms have been used in the past, and it’s essential that you use the most current, or correct, edition when submitting a claim via a paper form.

The HCFA/CMS‐1500 form is split into three sections. Section one is patient information. All this information should be in the patient’s registration form. Section two is for procedural and diagnostic information, which should be on the super‐bill or coding form. Section three is for the provider information. See? Easy as 1‐2‐3.

The UB‐04/CMS‐1450 form

The Uniform Bill 04 (UB‐04) claim form, also called the CMS‐1450 or just plain UB in some circles, is used by facilities for their health insurance billing. Hospitals, rehabilitation centers, ambulatory surgery centers, and clinics must bill their services on the UB‐04 form in order to get paid by commercial payers. There are 84 boxes on the UB‐04.

Required fields on the UB include revenue codes, bill type, and sometimes value codes in addition to the information required in the HCFA. Just as with the HCF/CMS‐1500, the directions are printed on the back of the form.