Beaverlog Tips:  Volume 34 - December 8, 2006

New CMS-1500 Claim Form

Both new versions of The THERAPIST include the new CMS-1500 form as well as retaining support for the old form. The big changes in the new form are the boxes for NPI for referring providers in box 17b, rendering providers in box 24j, facilities in box 32a, and billing providers in box 33a. For each of these, there is also an associated secondary identification and a qualifier code that indicates the type of ID used for the secondary identification number. The THERAPIST supports each of these directly on the appropriate entry screens.

Also new in the new form is that the service details are each now two lines high. The rendering provider NPI is on the bottom line while the secondary ID is on the top line, somewhat backwards from what seems natural. Most of the service information from the previous form is on the bottom line with Type of Service and COB columns going away and the EMG column moving to 24c leaving room for the new identification numbers sometimes placed in box 24k on the old form. Brand new is the supplemental information used to explain special circumstances. This 39 character field is on the top line starting just above the procedure code. Use of this field will depend on what your payers need to adjudicate your claims.

Much more subtle changes on the new form are slight adjustments to the positions of many of the form elements and position of the form on the page. This means that you may need to adjust your form alignment when you first begin using the new form. The Alignment tab on the setup screen let you move text up and down and left and right. An alignment test button will print the form with all possible data locations filled with text so that you can set your print margins accurately. The alignment settings for the new form are stored separately for the old form so both form alignments are retained.

Some payers are requiring the new form to be used beginning on January, 1 2007 and all payers will have to accept the new form starting May 23, 2007. This date corresponds with the date the provider NPI will be required. Since the old form doesn't directly support the NPI, it means that you are effectively required to switch over to the new form.


X12 Claim Specifications vs Payer Companion Documents

If you are submitting HIPAA standard ANSI X12 electronic claims (The THERAPIST Pro only), there are two documents that determine what can, what must, and what must not appear in your claims. The first of these is the version 4010 Implementation Guide and its addendum being considered as one document. The Implementation Guide (IG) is included on your installation CD in the Document folder as a pair of Adobe Acrobat files: X098.pdf (the original 768 page guide) and X098A1.pdf (the 86 page addendum). These documents are official specifications mandated by the federal government for all electronic health care claims submitted to payers. An exception in the law allows other formats for claims sent to clearinghouses but the clearinghouses must convert them to the X12 format to send them to the payers.

The 854 pages of the complete implementation guide give very detailed specifications on exactly what data appears where in the claim file. Payers are prohibited from changing or adding to the specification. They are, however, allowed to limit some of the information. For example, the IG doesn't indicate any particular limits on the Sender ID but a payer must limit this to IDs it assigns to providers who are approved to submit claims. Another frequent example is where a data element in the IG is neither required nor prohibited but is "Situational" and a Companion Document indicates that an entry is required under certain circumstances. There are may other possible examples. When a payer has additional requirements, these are described in a "Companion Document" which is made available to providers and other submitters and is the second of the two documents that describe what is included in and excluded from claim files.

Most of the time the two documents do not conflict but occasionally a Companion Document requires something not allowed in the IG or prohibits something the IG specifically allows. One example we came across was where a company indicated that it wanted a vendor ID in the 2010AA.PER05 element with a qualifier code of EM which is for an electronic mail address. This requirement is not allowed because the company was redefining a data element. When there is such a conflict, the IG always wins because it has the force of federal law behind it. This doesn't happen very often because, as detailed as the IG is, it is also very flexible and gives plenty of room for payers to indicate what they need in order to evaluate your claims.

At Beaver Creek Software, we watch for these conflicts. Sometimes, we discover them ourselves while reading a Companion Document but more often, our customers come to us when their claims are being rejected. When we find a conflict, we first try to resolve it with the payer. If they are unwilling to make the correction, we file a complaint with the Inspector General's office charged with enforcing HIPAA. In several cases these complaints have resulted in very large fines levied against the violator. These companies have become much more willing to work with us in getting such issues resolved.


Provider NPI Reminder

Do you have your NPI?  Don't wait and risk disrupting your cash flow.  Get your NPI now!  National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007 and every healthcare provider needs to get an NPI.  More information is available on the CMS web site:  This page has lots of other useful information as well. Be sure to bookmark this page as new information and resources will continue to be posted.

Additional information is available from the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative Website at