Details Of The CMS-1500 Claim Form - ABABilling
Rendering Provider SeriesPart 4Details of the CMS-1500 Claim FormAs organizations work with health insurance funders, one of the most critical items to thoroughlyunderstand is how to use the Rendering Provider appropriately on claims.The CMS-1500 Claim form has specific boxes to list the NPI numbers for the various types ofproviders based on the funder’s payor policy and requirements for submitting claims.In this blog, we will cover areas of the claim form. It is critical to read each payor policy or billingmanual for specific requirements for the funders an organization is working with.Find additional information in the other parts to this series: Part 1 Understanding NPI, Tax ID and Taxonomy CodesPart 2 Payor Contracts and the Connection to Rendering ProviderPart 3 Types of ProvidersPart 5 Billing Scenarios and Potential DenialsCMS-1500 CLAIM FORMVersion (02-12) is the standard claim form used by a non-institutional provider or supplier to billfor medical services. Boxes 17, 24J, 31, 32 and 33 list information about various providers. 2021 ABA Therapy Billing and Insurance ServicesPage 1 of 11
Rendering Provider SeriesPart 4REFERRING PROVIDERIf a Payor requires information related to the Referring Provider, Box 17 houses this informationon the claim form.Enter one of the following qualifiers to the left of the dotted vertical line, as appropriate, toidentify the role that the practitioner represents:Box 17a is not a required filed and should be left blank. Box 17b is where the National ProviderIdentification Number (NPI) is listed for the referring or ordering provider for ABA services. Thisis not the ABA provider from the organization, this is typically the member’s primary carephysician or the diagnosing physician.Along with Proof of Diagnosis which is provided with a fullcomprehensive report from a diagnosing physician, somemembers will have a prescription for ABA Therapy and forsome funders, this is a requirement. 2021 ABA Therapy Billing and Insurance ServicesPage 2 of 11
Rendering Provider SeriesPart 4RENDERING PROVIDERRendering providers render face-to-face services with members. In some cases, there may bea reimbursable non-face-to-face service provided. If a payor requires the individual renderingprovider’s NPI number on claims, it will be represented in Box 24J. TRICARE for example,requires each provider, including RBT ’s to be billed under the individual NPI number.RBT ’s should have their own individual NPI number.The supervising provider is the individual who provides oversight of the rendering providers whoperform services for members, as well as personally rendering specific services according totheir scope of practice. When the payor policy requires billing under the supervising qualifiedhealthcare professional (QHP), their NPI number is represented in Box 24J for all services.Only one NPI should be on each claim. 2021 ABA Therapy Billing and Insurance ServicesPage 3 of 11
Rendering Provider SeriesPart 4PAYOR POLICY GUIDELINE EXAMPLESIt is best practice to review and save off copies of all Payor policies and/or Billing manuals andwatch for updates.The TRICARE Operations Manual (TOM) Chapter 18 includes information for the Departmentof Defense (DoD) Comprehensive Autism Care Demonstration alHtmlFile/2021-0326/AsOf/TO15/C18S4.html?utm medium govdelivery&utm source emailExcerpts from the TOM related to areas covered in this Rendering Provider Blog Series:Note: Review for periodic updates to the TOM for the most up to date information.8.2.1 Obtain a National Provider Identifier (NPI) number (all claims must have the renderingprovider’s name and NPI for processing). For ABA providers who do not possess an NPI prior toJuly 1, 2021, these providers shall have until August 1, 2021 to obtain and submit an NPI. ForABA providers new to the ACD on or after July 1, 2021, providers must already possess an NPIat the time of certification application submission. TOP contractors shall follow Chapter 19, Section 4, paragraph 3.1 regarding provideridentification.8.11.4 The contractor shall ensure paid claims identify the name of the rendering provider foreach ABA service delivered, to include the NPI (see paragraph 8.2.1 for NPI requirements) ofthe rendering provider per unique claim line (i.e., every session must be identified as its ownunique line on any claim submitted).8.11.5 Application of Health Insurance Portability and Accountability Act (HIPAA) taxonomydesignation. All claims for ABS CPT codes must include the HIPAA taxonomy designation ofeach provider type. Each provider on a claim form must be identified by the correct HIPAAtaxonomy designation. The designations to be used are: 103K00000X Behavior Analyst for master’s level and above; 106E00000X Assistant Behavior Analyst; 106S00000X Behavior Technician; or Other appropriate HIPAA taxonomy based on license/certification 2021 ABA Therapy Billing and Insurance ServicesPage 4 of 11
Rendering Provider SeriesPart 4Excerpt from Florida Medicaid Payor Policy Guidelines:Note: Review for periodic updates to policy guidelines for the most up to date information.With Florida Medicaid, BCaBA's and RBT's are also required to obtain certification and be linkedto their group to bill for services as the rendering provider.Excerpt from Colorado Medicaid Payor Policy Guidelines:Note: Review for periodic updates to policy guidelines for the most up to date information.Colorado Medicaid states that the rendering providers must credential with them by having aBCBA certificate or be a Psychologist with a Masters or Doctorate. Therefore, billing the RBT as the rendering provider does not apply. 2021 ABA Therapy Billing and Insurance ServicesPage 5 of 11
Rendering Provider SeriesPart 4Excerpt from California Payor Policy Guidelines:Note: Review for periodic updates to policy guidelines for the most up to date informationspecific to the appropriate geographical Managed Care Organization (MCO).QAS Qualified Autism ServiceBMC Behavior Management ConsultantBMA Behavior Management AssistantSIGNATURE OF PROVIDER OF SERVICESThe Provider listed in Box 24J should match the signature in Box 31.It is important to list the Provider’s Credentials after the namein Box 31. 2021 ABA Therapy Billing and Insurance ServicesPage 6 of 11
Rendering Provider SeriesPart 4Here are a few payor guidelines:Note: Review for periodic updates to policy guidelines for the most up to date information.United Healthcare Community Plan of Washington:*LBA Licensed Behavior Analyst*LABA Licenses AssistantBehavior Analyst*CBT Certified BehaviorTechnicianAnthem Blue Cross Blue Shield:Nebraska Total Care: 2021 ABA Therapy Billing and Insurance ServicesPage 7 of 11
Rendering Provider SeriesPart 4SERVICE LOCATIONService location codes must be included on the CMS-1500 claim form to specify where serviceswere rendered.Below are common places of service for ABA Therapy services found on the CMS of-service-codes/Place of Service Code SetWhat if there is more than one location on the claim form?That is okay! Multiple locations can be billed on oneclaim form under ONE provider. 2021 ABA Therapy Billing and Insurance ServicesPage 8 of 11
Rendering Provider SeriesPart 4Here are a few payor guidelines:Note: Review for periodic updates to policy guidelines for the most up to date information.Alliance Payor:Nebraska Total Care: 2021 ABA Therapy Billing and Insurance ServicesPage 9 of 11
Rendering Provider SeriesPart 4BILLING PROVIDERIn Box 33, an organization is indicating who the billing provider is and instructing the payorwhere to send reimbursement.Here are a few payor guidelines:Note: Review for periodic updates to policy guidelines for the most up to date information.Cigna:Beacon Health Options: 2021 ABA Therapy Billing and Insurance ServicesPage 10 of 11
Rendering Provider SeriesPart 4Find additional information see other parts of this series: Part 1 Understanding NPI, Tax ID, and Taxonomy Codes Part 2 Payor Contracts and the Connection to Rendering Provider Part 3 Types of Providers Part 5 Billing Scenarios and Potential DenialsFor additional information on working with health insurance funders, check out our book atwww.capecodcollab.com – Revenue Cycle Management for ABA Therapy.Page 11 of 11 2021 ABA Therapy Billing and Insurance Services
Part 1 Understanding NPI, Tax ID and Taxonomy Codes Part 2 Payor Contracts and the Connection to Rendering Provider Part 3 Types of Providers Part 5 Billing Scenarios and Potential Denials . CMS-1500 CLAIM FORM . Version (02-12) is the standard claim form used by a non-institutional provider or supplier to bill
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Revised July 2012 Section 1500 Table of Contents Liens, Adjustment and Recoveries 1500.1 Introduction-Liens, Adjustment and Recoveries 1500.2 Court Order 1500.3Benefits Paid Pending Appeal Decision 1500.4 Liability 1500.5 Estates 1500.6 Voluntary Reimbursement 1500.7 Health Ins
