Payments > Insurance Payments

1500 CMC form

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gderilus:
u mean post copay on the cms 1500 form right

Michele:
As for the group NPI, it depends on if the provider (employer) bills using a legal business name and EIN/TAX ID number.  If they do, then a group NPI is needed.  If they bill under their name & ss # then only an individual.

As for the copay, you certainly must post it on the system, however, we have been advised by a MAJOR commercial carrier it is best NOT to report any patient payments on the claim form.  They told us that it messes things up.  You should always report the actual charges (NOT the charge minus any payment).  Personally, I feel that you should report the patient payment as well, but I thought I would share what we had been told.

Michele

melissa_2004:
Thanks for sharing that Michele,

I always thought we were to report what the patient paid also.  It seems we are not being honest if we don't however looking at  claims submitted it always shows the amount billed not subtracting what was paid.  Now I'm going, hmmmmmm ???  LOL

Melissa

PMRNC:
As somoene who spent quite a few years as a claims examiner, we really never looked at the "Pmt" box, but for any carrier to tell you NOT to does not make sense. That box if filled in and if pmt to provider is more than full fee will tag an alert to the examiner to check for assignment of benefits. So for example, let's say you submit a charge for an office visit $100.00 and the patient paid $20. You report the full charge and the copay is posted. Let's say the copay should only have been $10? Claim edits will alert the examiner but if there is an assignment of benefits the check will go to the provider and a note/tag will go into the file just in case a patient needs help in reclaiming that $10.  So I have no idea why any carrier would say NOT to fill it in. I worked for Prudential, BCBS, USLife (now AGI) and briefly at Cigna. All carriers have basically an identical system in place for claims processing.

Michele:
Well, as I said I personally don't agree, but it was BCBS that advised us, and many other providers at a seminar, not to include any payments on the CMS form.  Doesn't really make sense to me either, and we expressed our concern to them, but didn't get anywhere.

Michele

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