The medical healthcare sector provides treatment to everybody who comes for treatment. There are certain kinds of treatments that don’t involve the patient getting admitted to the hospital. They are known as outpatient treatments.
Outpatient treatments also need to be billed like other medical treatments and procedures.
As mentioned above, outpatient treatment is given to a patient with the same focus by the physician as he will to his other patients but as the treatment is not of extensive nature therefore the patient is not admitted to the hospital.
The outpatient treatment can be diagnostic tests, medications, and a consultation with the doctor. Now the question arises, what is the standard form used to bill outpatient claims?
The standard form that is used to bill outpatient claims is CMS-1500.
Let’s have a look at the CMS-1500 form in detail.
What is the standard form used to bill outpatient claims?
The CMS-1500 form is known to be the standard health insurance form used for submitting claims from physicians and other professionals for the basic providers.
For instance, if a physician is giving medical services at his private practice but provides exclusive services at an outpatient facility or a hospital then a CMS-1500 form will be prepared in order to bill the patient for the physician’s services.
Another form titled CMS-1450 also known as UB-04 is also used to make claims for outpatient services such as the laboratory, surgery, radiology, or any other relevant medical services.
The durable medical equipment (DME) uses CMS-1500 to submit outpatient claims.
The American Hospital Association (AHA) and the National Uniform Billing Committee (NUBC) are the authorities that look out for the outpatient claims made by these forms titled as CMS-1500 and UB-04.
The CMS-1500 form and the UB-04 form have a lot of similarities such as the patient demographics, medical procedures, and their charges, provider’s identification information, and the insurance plan.
Both the CMS-1450 and CMS-1500 forms help the physicians to make medical claims on the patient as well as get a reimbursement from the insurance company for the services that were provided by them. The insurance companies can reject the claim if certain criteria regarding the outpatient are not met.
Difference between CMS-1500 and CMS-1450 (UB-04)
The CMS-1500 and CMS-1450 forms might look similar on the outside because of similar tick boxes and information but in reality, they are really different from one another and are used for different purposes.
The two forms can never be used interchangeably. This is because there are twice more fields to be filled in the UB-04 form as compared to the CMS-1500 form. This is mainly because UB-04 deals with the outpatient claim made by large institutions such as hospitals etc. Here the services and medical procedure rendering are more complex than an individual physician.
Let’s have a look at these forms separately and check out their functions in detail:
CMS-1500 form
As mentioned above this is a standard form used to make health insurance claims to bill the Medicare providers. This form comes under Medicare Part-B.
The uniqueness of CMS-1500 is that this form is read with the help of Optical Character Recognition technology (OCR) which means that this form has to be filled with the help of red ink.
Thanks to the advent of technology, now physicians can submit this form electronically.
Even though the paper ones are still relevant. The payment of CMS-1500 forms depends on a lot of factors like the condition of the patient, the setting between the patient and the physician, and the network between the patient and the insurance company.
The CMS-1500 form has about 33 different fields that are designated to extract information about the patient such as his medical treatment procedures, his professional life, and personal information. All the claims of CMS-15000 need to be completed by the payer so the payments can be processed.
The electronic CMS-1500 forms must be informed before submission. A lot of patients might need third-party approval before making the claims to be processed further for reimbursements.
CMS-1450 also known as UB-04
The UB-04 form replaced the UB-92 form in 2007. The American Health Association (AHA) and the National Uniform Billing Committee (NUBC) monitor and passes rules and regulation regarding the UB-04 forms to make sure that they are updated timely and are useful for the physicians, other people involved in the medical profession, patients and of course of the third parties like the insurance companies.
The UB-04 form is used to make claims regarding the institutional facilities such as:
- Hospitals
- Hospices
- General health centers, rural clinics, and the federal health centers
- Rehab facilities such as occupational therapy, speech therapy, and physical therapy
- Specialized health centers such as renal health, rehabilitation clinics, and mental health institutes.
The UB-04 forms are also used to make claims regarding the facilities used in the laboratory, radiology, and surgery departments.
The CMS-1450 form is used to make outpatient claims under Medicare Part-A.
All the hospitals and medical institution providers can use this form to file claims. Institutional providers such as hospitals, rehab centers, mental health, and even organ procurement institutions can use this form to make claims for their payments.
It is very important to file accurate information of the payer in the form, especially the insurance company information as it must match with the information on the insurance card of the payer.
Always use the correct procedure and diagnosis codes even if the help of modifiers is required, that is allowed. Carefully, add the physical address of the medical institute or the facility so that the payer knows where the medical procedures took place.
Conclusion
The CMS-1500 and UB-04 forms are both developed to help the medical claim made by a patient to the insurance company regarding the outpatient treatment received by them. However, it is not easy to convince the insurance companies to reimburse the medical services provided by the physician and they can always reject the claim if it doesn’t match the criteria.
Both the forms provided information about the patient demographics, procedures, personal information, etc., but still, when it comes to getting reimbursement from the insurance company, the criteria get stricter. This is the mere reason the outpatient services claims must be filled out with immense care and focus so that the insurance companies cannot find any loophole or gray area and the payment is made dually.
