CMS-1500 and UB-04 Claims (Chapter 11)
What is the name of the medical claim form that is submitted by physicians? **** CMS-
1500
How should a patient's date of birth (DOB) be entered on a medical claim form? **** 11
03 1988
Data entry blocks on a UB-04 claim form that provide specific information necessary to
process a claim are called what? **** form locators
______ are submitted electronically to a third-party administrator, clearinghouse, or
payer using a computer with software that meets electronic submission requirements as
established by the Health Insurance Portability and Accountability Act (HIPAA) claim
standard. **** Claims
How are claims electronically transmitted? **** as data packets
unit of data routed from provider to clearinghouse, payer, or third-party administrator
using the Internet or other packet-exchange network. **** data packets
Rejected or denied claims that are not compliant with coverage and payment policy
requirements include what? **** errors that need to be corrected or reasons for denials
standard format used for submission of electronic claims for professional health care
services. Professional providers include physicians and suppliers. For example,
physicians submit Medicare claims to Medicare administrative contractors (MACs) and
durable medical equipment suppliers submit Medicare claims to DMEMAC. **** ANSI
ASC X12N 837P
physician or other health care practitioner or any entity other than a provider that
furnishes health care services. **** supplier
standard format for submission of electronic claims for institutional health care services.
Institutional providers include hospitals, SNF, end-stage renal disease providers, home
health agencies, hospices, outpatient rehab clinic, comprehensive outpatient rehab
facilities, community mental health centers, critical access hospitals, federally qualified
health centers, histocompatibility labs, Indian Health Service facilities, organ
procurement organizations, religious non-medical health care institutions, and rural
health clinics. For example, hospitals submit Medicare claims for inpatient admissions to
MACs **** ANSI ASC X12N 837I
standard format for retail pharmacy. For example, retail pharmacy submits Medicare
claims to the patient's Medicare Part D sponsor **** National Council for Prescription
Drug Programs (NCPCP) Telecommunication Standard
, organization that has 1 or more contracts with the Centers for medicare and Medicaid
Services to provide Part D benefits to Medicare beneficiaries **** Medicare Part D
sponsor
prescription drug coverage **** Medicare Part D
submitted electronically after being generated by medical practice management
software, and the ANSI ASC X12N 837P is the standard format used to electronically
transmit health care claims. **** CMS-1500 claim
What is used from a physician's office practice management software to populate the
CMS-1500 claim? **** patient data
designated as the CMS-1450 by CMS, uses ANSI ASC X12N 837I as its standard
format to electronically transmit health care claims for inpatient and outpatient
institutional services. **** UB-04 claim
When do claims require attachments? **** when CPT unlisted codes are reported
medical report substantiating the medical condition **** claims attachment
What should be included in claims attachment? **** patient and policy identification
information
Any letter written by the provider should contain clear and ______ English rather than
"medicalese." **** simple
requires the conversion of scanned images that contain print or cursive text into
machine-encoded text so computer software can read the text. **** optical character
recognition (OCR)
-Entering patient and policyholder names, provider names, and mailing addresses
(Telephone numbers are entered for providers.)
-Recovery of funds from responsible payers
-National provider identifier (NPI) and National standard employer identifier (EIN)
-Assignment of benefits versus accept assignment
-Reporting ICD-10-CM diagnosis codes and HCPCS Level II and CPT
procedure/service codes
-Reporting the billing entity **** Data entry for CMS-1500 requirments
For CMS-1500 claims, enter all alpha characters in _________. **** uppercase
For CMS-1500 claims, do NOT enter the alpha character "O" for a _____. **** zero
What is the name of the medical claim form that is submitted by physicians? **** CMS-
1500
How should a patient's date of birth (DOB) be entered on a medical claim form? **** 11
03 1988
Data entry blocks on a UB-04 claim form that provide specific information necessary to
process a claim are called what? **** form locators
______ are submitted electronically to a third-party administrator, clearinghouse, or
payer using a computer with software that meets electronic submission requirements as
established by the Health Insurance Portability and Accountability Act (HIPAA) claim
standard. **** Claims
How are claims electronically transmitted? **** as data packets
unit of data routed from provider to clearinghouse, payer, or third-party administrator
using the Internet or other packet-exchange network. **** data packets
Rejected or denied claims that are not compliant with coverage and payment policy
requirements include what? **** errors that need to be corrected or reasons for denials
standard format used for submission of electronic claims for professional health care
services. Professional providers include physicians and suppliers. For example,
physicians submit Medicare claims to Medicare administrative contractors (MACs) and
durable medical equipment suppliers submit Medicare claims to DMEMAC. **** ANSI
ASC X12N 837P
physician or other health care practitioner or any entity other than a provider that
furnishes health care services. **** supplier
standard format for submission of electronic claims for institutional health care services.
Institutional providers include hospitals, SNF, end-stage renal disease providers, home
health agencies, hospices, outpatient rehab clinic, comprehensive outpatient rehab
facilities, community mental health centers, critical access hospitals, federally qualified
health centers, histocompatibility labs, Indian Health Service facilities, organ
procurement organizations, religious non-medical health care institutions, and rural
health clinics. For example, hospitals submit Medicare claims for inpatient admissions to
MACs **** ANSI ASC X12N 837I
standard format for retail pharmacy. For example, retail pharmacy submits Medicare
claims to the patient's Medicare Part D sponsor **** National Council for Prescription
Drug Programs (NCPCP) Telecommunication Standard
, organization that has 1 or more contracts with the Centers for medicare and Medicaid
Services to provide Part D benefits to Medicare beneficiaries **** Medicare Part D
sponsor
prescription drug coverage **** Medicare Part D
submitted electronically after being generated by medical practice management
software, and the ANSI ASC X12N 837P is the standard format used to electronically
transmit health care claims. **** CMS-1500 claim
What is used from a physician's office practice management software to populate the
CMS-1500 claim? **** patient data
designated as the CMS-1450 by CMS, uses ANSI ASC X12N 837I as its standard
format to electronically transmit health care claims for inpatient and outpatient
institutional services. **** UB-04 claim
When do claims require attachments? **** when CPT unlisted codes are reported
medical report substantiating the medical condition **** claims attachment
What should be included in claims attachment? **** patient and policy identification
information
Any letter written by the provider should contain clear and ______ English rather than
"medicalese." **** simple
requires the conversion of scanned images that contain print or cursive text into
machine-encoded text so computer software can read the text. **** optical character
recognition (OCR)
-Entering patient and policyholder names, provider names, and mailing addresses
(Telephone numbers are entered for providers.)
-Recovery of funds from responsible payers
-National provider identifier (NPI) and National standard employer identifier (EIN)
-Assignment of benefits versus accept assignment
-Reporting ICD-10-CM diagnosis codes and HCPCS Level II and CPT
procedure/service codes
-Reporting the billing entity **** Data entry for CMS-1500 requirments
For CMS-1500 claims, enter all alpha characters in _________. **** uppercase
For CMS-1500 claims, do NOT enter the alpha character "O" for a _____. **** zero
