N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 18-A
(cf. Part 17)
STANDARD CLAIM FORM FOR PHYSICIAN SERVICES AND
CLAIM FORM INSTRUCTIONS
The Standard Claim Form for Physician Services, which is the Health Insurance Claim Form as approved by the American Medical Association Council on Medical Service 6-74, is designed for use by physicians treating patients who may be eligible for benefits from many different sources however, in conformance with law, the applicability of this standard claim form is limited to use where the patient is entitled to benefits from a commercial insurance company.
Accordingly, any reference in the standard claim form and instructions to payors other than commercial insurers should not be considered as part of the implementation of Chapter 545 of the Laws of 1977, but such references are retained in the claim form and instructions to permit the use of a form adapted to multi-payor use.
MEDICARE PAYMENTS: If the patient cannot write, have him sign by mark (X) and have a witness sign in item 12. If the patient cannot sign by mark, another person may sign, showing his relationship and indicating on the reverse of the form why the patient could not sign. A patient's signature requests that payment be made and authorizes releases of the medical information necessary to pay the claim. If item 9 is completed, the patient's signature authorizes releasing of the information to the insured or agency shown. In assigned cases, the physician agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the deductible are based upon the charge determination of the carrier, if this is less than the charge submitted.
MEDICAID PAYMENTS: I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the state's Title XIX plan and to furnish information regarding any payments claimed for providing such services as the state agency may request. I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductibles and coinsurance.
SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally rendered by me or under my personal direction.
NOTICE: Anyone who misrepresents or falsifies essential information to receive payment from federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable federal laws.
INSTRUCTIONS FOR COMPLETING THE FORM
The form has been separated into two major sections -- patient information and physician information. The patient and insured (subscriber) section contains eleven data elements and two spaces for signatures. Basically, this section captures patient name and address, insured's identifying number, and patient's and insured's signatures. The physician or supplier information section consists of twenty elements. There are, however, few circumstances that would require all of these elements to be completed.
A brief description of each element and its applicability to the requirements of Medicare, Medicaid, and insurance companies is presented below. For more specific information, consult your local intermediary or third party carrier. (For all Blue Shield and CHAMPUS claims, refer to local instructions provided by these organizations.)
It should be noted that "insured" as used in this booklet is the same as the policyholder or subscriber. The employee is the insured under group policies. "Dependents" refers to those persons eligible for coverage under the insured's policy. The term "patient" may refer to either the insured or a dependent.
ELEMENT 1.
The name of the patient must be filled in here as indicated.
ELEMENT 2.
Month, day and year of patient's birth.
ELEMENT 3.
The name of the insured should always be entered, except when the insured and the patient are the same -- then enter the word SAME.
ELEMENT 4.
It is necessary to furnish the patient's complete address for identification. It should be remembered that the first print line is for patient's street address and the second print line is for the city, state and zip code. It may also be necessary to complete the insured's address when it is different from the patient's. (See element 11 for insured's address if different. Otherwise, enter SAME in element 11).
ELEMENT 5.
The sex of patient must be indicated.
ELEMENT 6..
The insured's I.D. number, Medicare number and/or Medicaid number must be filled in; be sure to include any letters.
For Medicare this is the number on the beneficiary's red, white or blue health insurance card.
For Medicaid this is the I.D. number assigned by the local Agency.
For Blue Shield this is the number on the subscriber's identification card and is usually referred to as "Identification" or "Certificate" or "Contract" number.
For insurance companies this number is the insured's policy number or other identifying number assigned by the company.
For all others, use number assigned by the organization or agency.
ELEMENT 7.
The appropriate box should be checked.
ELEMENT 8..
For third party carriers this number is the policy number assigned to the group policyholder i.e., employer.
The Group name is preferred by most insurance companies.
ELEMENT 9..
This information is necessary to assist third parties in determining if the patient has multiple health insurance coverage, including Medicare. The name of the policyholder (insured) should be identified.
ELEMENT 10..
Part A.
This information is necessary for third parties to determine patient's eligibility for Workmen's Compensation Insurance..
Part B.
This information is necessary for determining the primary insurance carrier in those states with no-fault auto insurance laws.
ELEMENT 11..
Enter the insured's address if different from the patient's. Otherwise, enter SAME.
ELEMENT 12..
The patient's signature authorizes the provider to release medical information necessary to process the claim. It is anticipated that this simplified release of information statement will assist in limiting the release of confidential patient information. If patient is a minor, signature must be that of patient's parent or legal guardian. For the Medicare program, the beneficiary's signature also authorizes payment of the provider. Therefore, it is important that the physician complete element 26 when filing a claim for reimbursement.
ELEMENT 13..
This is the insured's authorization for the payment of benefits directly to the provider. Acceptance of this assignment is considered to be a contractual arrangement. If the insured desires the claim assigned, the insured's signature is necessary as a party to the contract. "Authorized person" must be the insured or person with power of attorney on behalf of insured.
ELEMENT 14.
If the patient consulted the provider as a result of illness, this element must contain the date of first symptoms.
If the patient consulted the provider as a result of an accident, this element must contain the date the accident occurred.
If the patient consulted the provider as a result of pregnancy, this element must contain the date of the last menstrual period (LMP). This information will assist third party carriers in determining patient eligibility for coverage.
ELEMENT 15..
Month, day and year patient first consulted the provider for the condition for which claim is being submitted. On subsequent visits for the same condition, it may not be necessary to complete this element.
ELEMENT 16..
Provider should check "yes" or "no". If "yes" is checked, it may be necessary for provider to attach a statement indicating when the patient had symptoms same as or similar to those for which claim is being submitted. On subsequent visits for the same condition, it may not be necessary to complete this element if a previous claim has been filed with the same third party carrier.
ELEMENT 17..
This element is to be completed only when the patient is entitled to disability benefits through insurance companies otherwise it can be left blank.
ELEMENT 18..
This element is to be completed only when the patient is entitled to disability benefits through insurance companies otherwise it can be left blank.
ELEMENT 19..
Must be completed for first consultations when a referring physician or other referring source (e.g., Public Health Agency) is involved. On subsequent visits for the same conditions it will not be necessary to complete this element.
ELEMENT 20..
This element need only be completed when medical service is rendered as a result of or subsequent to a related hospitalization.
ELEMENT 21..
If services are rendered in a hospital, clinic, laboratory or any facility other than patient's home or physician's office, name and address of facility must be entered.
ELEMENT 22..
If the answer is yes, the amount of the charges is requested and the name and address of the laboratory must be entered in element 21.
ELEMENT 23..
All third party carriers require that a diagnosis or nature of illness or injury be indicated before medical/health services will be considered as a covered expense. The diagnosis(es) should be written out or a coding structure may be used if such code is identified and is agreeable to carrier. When more than one diagnosis has been indicated on the claim form, relate each diagnosis (using reference number, i.e., 1, 2, 3 or DX code) to the appropriate procedures listed in element 24. This will greatly assist in collection of meaningful health care data. If a procedure relates to more than one diagnosis, the primary diagnosis to which the procedure relates should be the one referred to in Column D of element 24.
ELEMENT 24..
If elements 23 and 24 are properly completed, it is felt some of the additional correspondence currently generated by third party carriers will not be necessary and benefit payments will be made more promptly.
In Column A enter the month, day and year for each consultation or procedure. If "from" and "to" dates are shown here for a series of identical services, the number of these services should appear in Column C.
In Column B list the place of service utilizing the codes shown at the bottom of the form. Two coding structures have been identified. The first code is a one position primarily numeric code and must be used for reporting Blue Shield claims. The code shown in parentheses is a one to three position alphabetic code. Only one of these two coding structures should be used.
In Column C there is space for a written description of procedures and services performed as well as a box where a procedure code may be listed. If a coding structure is used, the coding structure must be identified and be agreeable to the carrier. For anesthesia, show the elapsed time (hours: minutes). If "from/to" dates were entered in Column A, the number of services should be entered here.
In Column D, the diagnosis reference number (i.e., 1, 2, 3 or the diagnostic code) as shown in element 23 should be filled in to more effectively relate the date of service and the procedures performed to the appropriate diagnosis.
In Column E, the charge for each listed service should be entered. Describing any unusual circumstances in Column C will help avoid claims processing delays related to unexplained charges.
In Column F, blank space has been provided primarily for use by Blue Shield. Refer to your local Blue Shield instructions.
ELEMENT 25..
The physician or supplier or his authorized representative must sign in element 25. Month, day and year the form was signed must also be provided.
ELEMENT 26..
The physician or supplier should check one of the boxes to indicate whether or not he accepts assignment of benefits under government funded programs. This does not include the Federal Employee Program.
ELEMENT 27.
ELEMENT 28.
ELEMENT 29.
These three elements relate to the accounting system of the physician or supplier and should be completed as determined appropriate.
ELEMENT 30.
The Social Security No. should be used by all physicians in private practice or by independent suppliers.
ELEMENT 31.
Element 31 is structured so that it may be completed by hand, typewritten or a rubber stamp. Some third parties or service organizations may preprint the doctor's name and number.
(Identifying) No. should be used when the physician or supplier is employed by a Health Maintenance Organization which has assigned him a special number, or is assigned a specific identifying number by a fiscal agent.
ELEMENT 32..
The patient's account number, as recorded in the physician or supplier accounting system, may be entered for additional patient identification.
ELEMENT 33..
The Employer I.D. No. should be completed when the physician or supplier is providing services in a group practice or is employed by a hospital or other institution and has been assigned an Employer I.D. No.
SPECIFIC REQUIREMENTS.
The following sections relate specifically to the requirements of Medicare, Medicaid, CHAMPUS, Blue Shield and insurance companies.
When Patient is Covered by Medicare Items that must be considered for completion as applicable:.
1, 2, 4-6, 9, 10, 12, and 19-33..
.
Items that need not be considered for completion:.
3, 7, 8, 10B, 11, 13, and 14-18. Additional instructions are published by SSA.
When Patient is Covered by Medicaid All items should be considered for completion as applicable for Medicaid patients except items 17 and 18..
.
For additional information confer with the Medicaid intermediary.
When Patient is covered by CHAMPUS Additional instructions are prepared by CHAMPUS.
When Patient is Covered by Blue Shield Check with your local Blue Shield Plan concerning the Health Insurance Claim Form and separate instructions.
When Patient is Covered by Insurance All items on the form must be considered for completion when the patient is insured by third-party coverage other than A through D above. While most items are self-explanatory as to what information is to be provided, special attention must be given to items 6, 8, 9, 10 and 13 in the Patient and Insured (Subscriber) Information section and to items 14, 17, 18, 23 and 24 in the Physician or Supplier Information.
N.Y. Comp. Codes R. & Regs. tit. 11, Appendices, app 18-A