Paper Claim Form Preparation And Data Alignment .
UpdateJune 2008No. 2008-45Affected Programs: All ProgramsTo: All Providers, HMOs and Other Managed Care ProgramsPaper Claim Form Preparation and DataAlignment Requirements for ForwardHealthinterChangeThis ForwardHealth Update provides information aboutthe paper claim form preparation and data alignmentrequirements for 1500 Health Insurance Claim Formand UB-04 Claim Form. These requirements will helpassure that claim forms are aligned correctly in order tooptimize speed of processing using optical characterrecognition software. This Update also gives informationabout electronic claims submission options. Theinformation in this Update does not apply to AmericanDental Association claim forms or the pharmacyCompound Drug Claim, F-13073 (10/08), andNoncompound Drug Claim, F-13072 (10/08).Implementation of ForwardHealthinterChangeIn October 2008, the Department of Health and FamilyServices (DHFS) will implement ForwardHealthinterChange, which replaces Wisconsin’s existingMedicaid Management Information System (MMIS).ForwardHealth interChange will be supported as part ofthe State's new fiscal agent contract with EDS. WithForwardHealth interChange, providers and tradingpartners will have more ways to verify memberenrollment and submit electronic claims, adjustments,and prior authorization requests through the secureForwardHealth Portal. Refer to the March 2008ForwardHealth Update (2008-24), titled "Introducingdetailed outline of the many business processenhancements and added benefits the new system andfiscal agent contract will provide.These requirements apply to all ForwardHealthprograms except as noted.Optical Character RecognitionPaper claims submitted to ForwardHealth on the 1500Health Insurance Claim Forms and UB-04 Claim Formswill be processed using Optical Character Recognition(OCR) software that recognizes printed, alphanumerictext. Optical Character Recognition software willincrease efficiency by alleviating the need for keying indata from paper claims. Optical Character Recognitionsoftware will only read current versions of the paper1500 Health Insurance Claim Forms and the UB-04Claim Forms. Older versions of the 1500 HealthInsurance and the UB-04 paper claim forms, includingthe UB-92 paper claim form, will not be accepted.Information in this Update does not apply to AmericanDental Association claim forms or pharmacy CompoundDrug Claim, F-13073 (10/08), and Noncompound DrugClaim, F-13072 (10/08).ForwardHealth interChange, a New Web-BasedInformation System for State Health Care Programs,"for an overview of the implementation and a moreDepartment of Health and Family Services
Speed and Accuracy of Claims Processingneed to be keyed manually from an electronic image ofOptical Character Recognition software processes claimthe claim form. This could result in processing delays.forms by reading text within fields on claim forms. Aftera paper claim form is received by ForwardHealth, theUse Laser or Ink Jet Printersclaim form is scanned so that an image can be displayedIt is recommended that claims are printed using laser orelectronically. The OCR software reads the electronicink jet printers rather than printers that use DOTimage on file and populates the information into thematrix. DOT matrix printers have breaks in the lettersForwardHealth interChange system. This technologyand numbers, which may cause the OCR software toincreases accuracy by removing the possibility of errorsmisread the claim form. Use of old or worn inkbeing made during manual keying.cartridges should also be avoided. If the claim form isread incorrectly by the OCR software, the claim may beOptical Character Recognition software will speed paperdenied or reimbursed incorrectly. The process may alsoclaim processing, but only if providers prepare theirbe stopped if it is unable to read the claim form, whichclaim forms correctly. In order for OCR software towill cause a delay while it is manually reviewed.read the claim form accurately, the quality of copy andthe alignment of text within individual fields on theAlignmentclaim form need to be precise. If data are misaligned, theAlignment within each field on the claim form needs toclaim could be processed incorrectly. If data cannot bebe accurate. If text within a field is aligned incorrectly,read by the OCR software, the process will stop and thethe OCR software may not recognize that data areelectronic image of the claim form will need to bepresent within the field or may not read the datareviewed and keyed manually. This will cause ancorrectly. For example, if a reimbursement amount ofincrease in processing time. 300.00 is entered into a field on the claim form, but theHandwritten ClaimsSubmitting handwritten claims should be avoidedlast “0” is not aligned within the field, the OCR softwaremay read the number as 30.00, and the claim will bereimbursed incorrectly.whenever possible. ForwardHealth will continue toaccept handwritten claims; however, it is very difficultTo get the best alignment on the claim form, providersfor OCR software to read a handwritten claim. If ashould center information vertically within each field,handwritten claim cannot be read by the OCR software,and align all information on the same horizontal plane.it will need to be keyed manually from the electronicAvoid squeezing two lines of text into one of the six lineimage of the claim form. Providers should avoiditems on the 1500 Health Insurance Claim Form. Refersubmitting claims with handwritten corrections as thisto Attachments 1-4 of this Update for examples of 1500can also cause OCR software processing delays.Health Insurance and UB-04 claim forms that are alignedcorrectly and incorrectly.Use Original Claim FormsOnly original 1500 Health Insurance Claim Forms andClarityUB-04 Claim Forms should be submitted. Original claimClarity is very important. If information on the claimforms are printed in red ink and may be obtained from aform is not clear enough to be read by the OCRfederal forms supplier. ForwardHealth does not providesoftware, the process may stop, prompting manualthese claim forms. Claims that are submitted asreview.photocopies cannot be read by OCR software and willForwardHealth Provider Information z June 2008 z No. 2008-452
The following guidelines will produce the clearest imageelement so that it can be read properly by the OCRand optimize processing time:software, providers should indicate the fifth diagnosis Use 10- or 12-point Times New Roman or Couriercode between the first and third diagnosis code blanks,New font.the sixth diagnosis code between the second and fourthType all claim data in uppercase letters.diagnosis code blanks, the seventh diagnosis code to theUse only black ink to complete the claim form.right of the third diagnosis code blank, and the eighthAvoid using italics, bold, or script.diagnosis code to the right of the fourth diagnosis codeMake sure characters do not touch.blank. Providers should not number any additionalMake sure there are no lines from the printerdiagnosis codes. cartridge anywhere on the claim form. Avoid using special characters such as dollar signs,Anchor Fieldsdecimals, dashes, asterisks, or backslashes, unless it isAnchor fields are areas on the 1500 Health Insurancespecified that these characters should be used.Claim Form and the UB-04 Claim Form that the OCRUse Xs in check boxes. Avoid using letters such assoftware uses to identify what type of form is being“Y” for “Yes,” “N” for “No,” “M” for “Male,” orprocessed. The following fields on the 1500 Health“F” for “Female.”Insurance Claim Form are anchor fields:Do not highlight any information on the claim form. Highlighted information blackens when it isimaged, and the OCR software will be unable toElement 2 (Patient’s Name).Element 4 (Insured’s Name).Element 24 (Detail 1).read it.The following fields on the UB-04 Claim Form areNote: The above guidelines will also produce the clearestimage for claims that need to be keyed manually from anelectronic image.Staples, Correction Liquid, and CorrectionTapeThe use of staples, correction liquid, correction tape,labels, or stickers on claim forms should be avoided.Staples need to be removed from claim forms beforethey can be imaged, which can damage the claim andcause a delay in processing time. Correction liquid,correction tape, labels, and stickers can cause data to beread incorrectly or cause the OCR process to stop,prompting manual review. If the form cannot be read bythe OCR software, it will need to be keyed manuallyanchor fields: Form Locator 4 (Type of Bill).Form Locator 5 (Fed. Tax No.).Form Locator 9 (Patient Address).Form Locator 58A (Insured’s Name).Since ForwardHealth uses these fields to identify theform as a 1500 Health Insurance Claim Form or a UB-04Claim Form, it is required that these fields are completedfor processing. Watch for future service-specific claiminstruction publications for information on what toinclude in anchor fields on 1500 Health Insurance ClaimForms and UB-04 Claim Forms.Electronic Claims Submissionfrom an electronic image.While the OCR software will speed paper claimsAdditional Diagnosis Codesprocess claims is through electronic claims submission.processing considerably, the most efficient way toForwardHealth will accept up to eight diagnosis codes inElement 21 of the 1500 Health Insurance Claim Form.To correctly add additional diagnosis codes in thisForwardHealth Provider Information z June 2008 z No. 2008-453
Providers may submit claims using the followingelectronic submission options: ForwardHealth Portal.Provider Electronic Solutions software.837 Health Care Claims for Electronic DataInterchange. National Council for Prescription Drug Programs.Watch for future publications for information onsubmitting claims electronically.The ForwardHealth Update is the first source of programpolicy and billing information for providers.Wisconsin Medicaid, BadgerCare Plus, SeniorCare, andWisconsin Chronic Disease Program are administered bythe Division of Health Care Access and Accountability,Wisconsin Department of Health and Family Services(DHFS). Wisconsin Well Woman Program isadministered by the Division of Public Health, WisconsinDHFS.For questions, call Provider Services at (800) 947-9627or visit our Web site atdhfs.wisconsin.gov/forwardhealth/.PHC 1250ForwardHealth Provider Information z June 2008 z No. 2008-454
ATTACHMENT 1Sample of a Correctly Aligned 1500 HealthInsurance Claim FormThe following sample 1500 Health Insurance Claim Form is an example of how claims data should be correctly aligned on the form.Providers are reminded that when submitting claims, the text must be correctly aligned in both the cell and the row, or the claim will deny.X1234567890RECIPIENT, IM A.MMDD YYX609 WILLOW STANYTOWN55555WIXXX XXX-XXXXOI-PM-8I.M. REFERRING PROVIDER0123456780XXXXXX . XXXXXXXX . XXXXXXXX . XXXXXXXX . XXMM DD YYXXXXXXXXX1234JEDI.M. Provider MM/DD/YYForwardHealth Provider Information z June 2008 z No. 2008-45XXXX XX1XXX XXZZ 123456789X0111111110XX XXXX XXI.M. PROVIDER1 W WILLIAMS STANYTOWN WI 55555-12340222222220 ZZ123456789X5
ATTACHMENT 2Sample of an Incorrectly Aligned 1500 Health InsuranceClaim FormThe blue text in the following sample 1500 Health Insurance Claim Form is incorrectly aligned within the cell. The red text has beenincorrectly aligned within the row. Providers are reminded that when submitting claims, the text must be correctly aligned in both the celland the row, or the claim will deny.X1234567890RECIPIENT, IM A.MM DD YYX609 WILLOW ST.ANYTOWNWI55555XXX XXX-XXXXOI-PM-8I.M. REFERRING PROVIDER0123456780XX XXXX . XXXX XXXX . XXXX XXXX . XXXX XXXX . XXZZ 123456789XMM DD YYXXXXXXX XX1234JEDI.M. Provider MM/DD/YYForwardHealth Provider Information z June 2008 z No. 2008-45XXXX XXXXX XX10111111110XX XXXX XXI.M. PROVIDER1 W WILLIAMS STANYTOWN WI 55555-12340222222220ZZ123456789X6
ATTACHMENT 3Sample of a Correctly Aligned UB-04 Claim FormThe following sample UB-04 Claim Form is an example of how claims data should be correctly aligned on the form. Providers are remindedthat when submitting claims, the text must be correctly aligned in both the cell and the row, or the claim will deny.IM BILLING PROVIDER1 W. WILSONANYTOWN WI 55555(444) 444-4444JED123403 7654321234567890555 ORBITING DRIVE, WESTHILL, WI 52345RECIPIENT, IM XX XXXXX XXDDDDXXX XXMEDICAREXYZ INSURANCET19 MEDICAIDIM INSUREDXX XX876543211234567890XXXXXPROVIDER1D 12345678I.M.M-7ForwardHealth Provider Information z June 2008 z No. 2008-457
ATTACHMENT 4Sample of an Incorrectly Aligned UB-04 Claim FormThe blue text in the following sample UB-04 Claim Form is incorrectly aligned within the cell. The red text is incorrectly aligned within therow. Providers are reminded that when submitting claims, the text must be correctly aligned in both the cell and the row, or the claim willdeny.IM BILLING PROVIDER1 W. WILSONANYTOWN WI 55555(444) 444-4444JED123403 765432RECIPIENT, IM A07151955XXX1234567890555 ORBITING DRIVE, WESTHILL, WI 52345F05500580XXXXXXXXXXMMDDYYMMDDYY1.01.0XXX XXXXX XXDDDDXXX XXMEDICAREXYZ INSURANCET19 MEDICAIDXX XX87654321IM INSURED1234567890XXXXXPROVIDER1D 12345678I.M.M-7OI-PForwardHealth Provider Information z June 2008 z No. 2008-458
Optical Character Recognition software will speed paper claim processing, but only if providers prepare their claim forms correctly. In order for OCR software to read the claim form accurately, the quality of copy and the alignment of
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Submission Reason: Choose Original if you are submitting a new claim or resubmitting a previously denied or rejected claim. Choose Replace if you are submitting an Adjustment and choose Void if you are voiding a claim. If you choose Replace or Void, you must enter the Payer Claim Control Number of the paid claim. This number is reported on the provider's remittance as the Transaction Control .
NCPDP VERSION D.0 Claim Billing/Claim Re-bill Template December 1, 2014 ** Start of Request Claim Billing/Claim Re -bill (B1/B3) Payer Sheet Template** General Information Payer Name: Magellan Rx Management Date: December 1, 2014 Plan Name/Group Name: EFFECTIVE 12/01/14 CBA Blue BIN: 017449 PCN: CBG
Certified Family Homes Billing Tips 03/02/2021 Page 3 Edit/Adjudicate Options After you have submitted your claim, the Claim Confirmation page will display (Figure 4). Figure 4: Claim Confirmation The claim ID displays in the upper left corner of the confirmation page. Select the Claim View link to see the detail of claim.
Aug 05, 2019 · Member Dental Claim Form Submit this claim form for services which may be covered under your dental benefits. Complete a separate claim form for each patient and ensure all information is complete and accurate. All questions must be answered or the form will be returned to . the Blue Cross and Blue Shield Association
23. Date of Claim Form Date the claim form was signed by the provider or the date the claim was transmitted electronically. 24. Claim Total Billed Total amount billed for the claim. 25. RA Number XX/00000 First two digits identify the processing cycle. The five digits following the slash (/) identify the particular RA within the cycle.
The Medicare claim may be submitted to Medicare on the professional claim form (837p) or the institutional claim form (837i). Which claim form is used depends on which enrollment form the provider uses to enroll in Medicare, the CMS-855B for use of the 837p or the CMS-855A for use of the 837i. If the 837i is used to bill Medicare, and
courts interpret laws, adjudicate dis-putes under laws, and at times even strike down laws as violating the fun-damental protections that the Consti-tution guarantees all Americans. At the same time, millions of Americans transact their day-to-day affairs with-out turning to the courts. They, too, rely upon the legal system. The young
