This segment of face sheet contains all active insurance information of the patient. This segment includes primary, secondary, and/or tertiary insurance information. This segment is the most important field in patient demographic sheet. Information found in this field should always be the updated & correct one. If not, we would be submitting claims to incorrect insurance. Entry persons should always match this information with copy of insurance id cards. (if provided). This will reduce the risk of entering incorrect insurance information. Following information are found in this segment
1. Insurance Code/Name
2. Effective Date
3. Subscribers Name
4. Relationship Code
5. Pre-Certification/Pre-Authorization
6. Referral Number
7. Primary Insurance Group #
8. Primary Insurance Policy #
9. Date of Injury/Accident
10. Claim Number
1. Insurance Code/Name: This field is used to enter the insurance code or name of the coverage that the patient has. The insurance code is assigned by the Billing office for its internal purpose to reduce the PD entry time. Each Insurance company’s name, billing address, contact person, etc… are assigned a unique code. The entry person should be very careful while selecting the insurance code and should always verify the billing address with the given card copy or with the billing address given on the encounter form.
The Primary insurance name is printed in the 11c field and the Secondary insurance name is printed in the 9d field of the CMS-1500 claim form.
Example:
Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …
2. Effective Date: This field contains the effective date of coverage. This date should not be after the Date of Service. The date format is MMDDYYYY. This date is used for the internal purpose of the Billing office and Hospitals. This does not form part of the HCFA-1500 claim form.
Example:
Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …
3. Subscribers Name: This field contains the Subscribers name of the insurance policy. If the patient is a dependant who is covered under someone else’s policy then the name of the person who pays the premium is entered in this field. If patient is the subscriber then we need to enter the patient name itself. The name is entered in the Last Name, First Name MI format.
The Primary insurance subscribers name is printed in the 4th field and the Secondary insurance subscribers name is printed in the 9th field of the CMS-1500 claim form.
Example:
Subscriber: John Q. Public; Public, John Q …
4. Relationship Code: This field contains the relationship of the subscriber to the patient. The code is usually 1 – Self, 2 – Spouse, 3 – Parent, 4 – others etc…
This field does not form part of the CMS-1500 claim form.
5. Policy ID: This field contains the Policy number given by the insurance company to the subscriber and the dependants of the policy. This does not have any standard format across the insurance company but each insurance company has a unique format such as for Medicare the policy number is given as SSN + Alpha or Alphanumeric. The policy ID should be entered as given in the scanned card copy or as mentioned on the Encounter form.
The Primary insurance ID is printed in the 11th field and the Secondary insurance ID is printed in the 9a field of the CMS-1500 claim form.
Example:
Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …
6. Group ID: This field contains the Group ID as given by the insurance company for the policy. Not all the insurance companies have the Group ID hence if not given then this field can be left blank.
The Group ID is printed along with the Policy ID on the CMS-1500 claim form.
7. Pre-Auth. / Pre-Cert. Number: Review of “need” for inpatient care or other care before admission. This refers to a decision made by the payer, Managed Care Organization, or insurance company prior to admission. The payer determines whether or not the payer will pay for the service. Most managed care plans require pre-cert. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered. An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, monitoring one or more of the following: patient’s eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors, and maximums. Under some programs, for instance, pre-determination by the third party is required when covered charges are expected to exceed a certain amount. This number should be attached with the respective claim; otherwise the claim will be rejected. There is no standard format for Auth and Pre-Cert. number across all the insurance companies. Each insurance company has its own unique format of Auth and Pre-Cert. numbers.
This field is printed in the 23rd field of the CMS-1500 claim form.
8. Referral Number: A Referral number is provided by a PCP (Primary Care Physician) when he refers a patient to a specialist. Without the Referral number a patient cannot get a specialist’s service if he has a HMO plan.
This number is printed on the CMS-1500 claim form or entered in the attached documents as per the Insurance company requirements.
9. Date of Injury/Accident: This field is used to enter the Date of Injury/Accident when the claim is filed to Work Comp/Auto Accident insurance. This date is useful for the insurance companies to verify if the coverage was active or not. This date is mentioned in the documents attached while filing the claim.
10. Claim Number: This field is used to enter the Claim number for a particular claim given by the Work Comp/Auto Accident insurance company. Failing to mention this number on the claim form will result in the rejection of the claim.
This is mentioned in the attached documents while submitting the claim.
6. Marital Status: This field contains the Marital Status of the patient. It is usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for Widow/Widower, ‘X’ for Separated and ‘O’ for Others. It marital status is missing from patient encounter form, we need to enter ‘O’ in the marital status field.
This field is printed in the 8th field of the CMS-1500 claim form.
Example:
Marital Status: Single; Married; Divorced; Widow …
7. Address: Patient’s address is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Appt. #), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. This field can not be left blank. Patient address is a important field to file a claim & send patient statement. Following are the general abbreviations found in patient encounter forms:
a) Apt. # – Apartment number
b) Ave. – Avenue number
c) Blvd. – Boulevard
d) Ste. – Suite/Street
e) Dr. – Drive
This field is printed in the 5th field of the CMS-1500 claim form.
Example:
Address: 1067 Orange Grove Blvd.
Apt. # 194
Los Angeles, CA 90001
8. Patient Phone Number: This field contains the contact number of the patient including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications.
This field is printed in the 5th field of the CMS-1500 claim form along with the address.
Example:
Phone Number: 626-843-2846; (626)357-5496 …
II. Patient Employer information
This segment in the face sheet contains employer information of the patient. The entry person needs to enter this information if available in face sheet. Employer information is a must for worker’s comp claims. Non-worker’s comp claims do not require employer name to process claims but it is advisable to update employer information during entry. Following information’s are found in this segment
1. Employer Code
2. Employer Name
3. Employer Address & Phone #
4. Designation/Occupation
5. Contact Person
1. Employer Code: This field is used in most of the Billing Software’s to reduce the time of PD entry. The Names and Addresses of the major Employers are stored in the Employer database with a unique code assigned to each employer. Hence it is enough to just enter the code and skip to the next block.
Example:
Employer Code: IBM; A0012; MS024 …
2. Employer Name: This field contains the name of the patients Employer. If the patient is a Student or Not Employed or Retired then it can be entered as Student or Not employed or Retired in this field.
This field is printed in the 11b field of the CMS-1500 claim form.
Example:
Employer: Verizon Wireless; Microsoft Corp.; SUN Microsystems …
3. Employer Address: The address of the patients Employer is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code.
Example:
Address: PO Box 1954
Los Angeles, CA 90001-1954
4. Employer Phone Number (Ext No.): This field contains the contact number of the patients Employer including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Some software’s may also require you to enter the Extension number if given on the encounter form.
Example:
818-245-7849 [5478]; (818)-245-7849 …
III. Patient Guarantor Information
This segment in face sheet consists of guarantor or emergency contact information.
They are:
1. Guarantor Account #
2. Guarantor Name
3. Guarantor Address
4. Guarantor phone #
5. Guarantor/patient relationship
6. Guarantor employer & SSN
This block is mostly entered only in the case of the patient being a minor or if the patient is not responsible for the payment. This information is for the internal purpose of the Billing Office and the Hospitals for the purpose of Emergency Contact or follow-up of pending balances and hence does not form part of the CMS-1500 claim form.
1. Guarantor Account #: This field is used to enter the guarantor account #. If the guarantor is already stored in the database then the stored information can be pulled up using this number. This information is not part of the encounter form. The account number of the guarantor is pulled using search engine.
Example:
245818A; 6252315; 421154; …
2. Guarantor Name: This field is entered in the Last Name, First Name Middle Initial format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The guarantor name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications.
Example:
Joseph Warowes Sr.; Warowes, Virginia E M.D …
3. Relationship: This field contains the relationship of the Guarantor with the patient, such as Spouse, Parent, Others etc.
Example:
Relationship: Spouse; Parent; Grand Parent …
4. Address: The address of the Guarantor is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code.
Example:
102 West 35th Street
Heathsville, GA 65418
5. Phone Number: This field contains the contact number of the Guarantor including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications.
Example:
(517)373-1820; 517-374-5857 …
6. Guarantor Employer: This field contains the guarantor’s employer information. Basically the guarantor’s employer name, address, and contact details are entered here.
7. Emergency Contact: This field is used to enter the Emergency Contact details of the patients relative or next of kin. Contact information such as Name, Address Phone # and relation to the patient are entered here.
IV. Physician Information
This segment contains the following information.
1. Admitting physician code: The physician responsible for admission of a patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility), called an admitting physician. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. This field is optional; if the Admitting physician info is not given it can be left blank.
This field does not form part of the HCFA-1500 claim form.
Example:
Adm. Phy.: Mileski MD, William
2. Attending or Rendering physician code: The physician rendering the major portion of care or having primary responsibility for the care of the patient’s major condition or diagnosis. In other words the doctor or supplier who actually renders the service (also referred to as a “rendering physician”). All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details.
The Name of the rendering physician is printed in the 33rd field along with the Address and Phone #. The rendering physician’s Federal tax ID stored in the database is automatically printed in the 25th field of the CMS-1500 claim form.
Example:
Att. Phy.: Pendridge MD, X
3. Referring Physician/Primary Care physician code: The physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is called a referring Physician or Primary Care Physician (PCP). The name of the facility may be reflected in this area if the patient has not identified a unique physician, but has identified a facility. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details.
The name of the referring physician is printed in the 17th field and the corresponding UPIN stored in the database is printed in the 17a field of the CMS-1500 claim form.
1. Attending Physician: Attending physician is also referred as rendering physician. A physician who renders the service to patients is called attending or rendering physician. Each Rendering/Attending Physician of a particular facility is assigned a unique code with the Name of the Physician, Address of the Clinic/Facility, PIN (Provider Identification Number), License number, Federal TaxID#.
The Rendering Physician Name, Address, and PIN are printed in the 33rd field and if the Address of the Facility where the service was rendered differs from the Physicians location then that address is printed in the 32nd field and the corresponding Federal Tax ID of the Provider is printed in the 25th field of CMS-1500 form.
2. Referring Physician: Physician who refers patient to specialists is called referring Physician or Primary Care Physician (PCP) information is integral to continuity of care, reimbursement and community relations. In simple words, the physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is known as a Referring Physician. Each Referring Physician is allotted a unique code in the Medical Billing software which stores the Name of the Physician, Address of the Clinic/Facility, UPIN (Unique Physician Identification Number).
The Referring Physician Name is printed in the 17th field of the CMS-1500 claim form. The UPIN which is stored along with the code is printed in the 17a field of the CMS-1500 claim form.
3. Admit Date: Admit date refers to the date in which patient was admitted into the Hospital. For workers compensation Date of Injury (DOI) is very important for processing the claim. For the purpose of determining the date of injury for an occupational disease, the date of injury shall be taken to be the last date of injurious exposure to the hazards of such disease or the date on which the employee first knew or reasonably should have known of the condition and its relationship to the employee’s employment, whichever is the later.
4. Date of Service: DOS is the date in which services were rendered to patient by attending physician. In certain cases we have thru date of service and also it will be in the single date format. Standard format for entering DOS is mm/dd/yyyy. DOS must be greater than or equal to admit date.
5. Type of Service: We need to input the type of service which was administered to patient. Broadly we have two digit TOS codes which needs to be entered in block 24C of CMS-1500 form. The type of service defines what type of service it is like radiology, cardiology and etc.
6. Place of Service: Two digit place of service needs to be entered in block 24b of CMS-1500 form while submitting claims to insurance carriers. POS can be for inpatient, Outpatient & ER. Health care that you get when you are admitted to a hospital is an inpatient. Medical or surgical care that does not include an overnight hospital stay is an outpatient. Care given for a medical emergency when you believe that your health is in serious danger when every second counts is an Emergency care. This field consists of the place or the location where services were provided to the patient. Location details are printed in block 32 of CMS-1500 form. Details like location name, address are printed. Where services are rendered in patient’s home & physician’s office location details in CMS-1500 form can be blank.
7. Preauthorization: An insurance plan requirement in which you or your primary care physician must notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense. Preauthorization are of two types. 1) Requesting authorization of date of services that have not been previously requested or the request was previously rejected. 2) Requesting authorization for increase or decrease units for previously approved dates of service. In other words, Preauthorization means Insurance is notified in advance about specific procedures. This allows for a review of medical necessity, efficiency, and quality of proposed care. It is also an opportunity to inform patient/physician about benefits, including length-of-stay guidelines and plan limitations. This will help to understand the costs if patient receive the proposed care.
8. Procedure Code: Procedure codes are used to indicate the kind of treatment or service was administered in patient. Utmost care should be given while entering the procedure code. We need to first know what kind of procedure code each insurance accepts to process claims. Healthcare Common Procedure Coding System (HCPCS) is a coding system that is composed of Level I codes (Current Procedural Terminology (CPT) codes), Level II codes (national codes), and Level III codes (local codes). Level I (CPT) codes are five digit numeric codes that describe procedures and tests. CPT codes are developed and maintained by the AMA with annual updates. Level II (national) codes are five digit alpha numeric codes that describe pharmaceuticals, supplies, procedures, tests and services. Level II codes are developed and maintained by CMS with quarterly updates. Level III (local) codes are five digit alpha numeric codes that are being phased out by the fiscal intermediaries.
Examples of CPT codes:
• 85025 – CBC with automated differential
• 71020 – Chest x-ray 2 views
• 45378 – Colonoscopy
• 93501 – Right heart catheterization
In other words, this field contains the Code of the procedure done (CPT/HCPCS Code). The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. All the Procedure codes are stored in a Master database of the Medical Billing software with the description of the code and the dollar amount. This helps the charge entry person to cross verify the procedure before saving the claim.
This field is printed in the 24d field and the corresponding dollar amount of the procedure stored in the Medical Billing Software is printed in the 24f field of the CMS-1500 claim form.
