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What Is HCFA in Medical Billing?

HCFA medical billing FormThere are specific protocols when billing with insurance companies. One of those protocols is filling out form HCFA. Here’s what to know about this form.

The Health Care Finance Administration (HCFA) form is a claim form used in settlement of government insurance programs such as Medicare and Medicaid to medical providers. Developed by The Center of Medicaid and Medicare (CMS) but was adopted as a standard form by all Insurance plans.

Clinical practitioners and physicians use the HCFA to submit claims for professional services. Federal regulations require all healthcare providers to use the HCFA or UB-04 form for filing claims.

Keep on reading to learn more!

The HCFA/CMS-1500

This form is universal, and all healthcare providers use them to bill health insurance providers. Both Medicaid and Medicare, part B services, are billed using this form. The National Uniform Claim Committee (NUCC) maintains this form.

The HCFA contains all the essential info required to submit a precise claim. In this form, the healthcare provider should include the following;

  • Patient’s demographic information
  • Patient’s insurance information
  • Medical Codes
  • Dates of service

The information filed in this form should be accurate and factual. To avoid disputes, healthcare providers should be truthful when filling the form. In case the insurance detects irregularities, they may fail to honor the claims.

There is a specific box that applies to each health provider. The payer might provide different info on how to fill some boxes. The medical coder and biller must be familiar with some specific payer requirements.

How Does the HCFA Form Work?

Firstly, the healthcare provider treats a patient and then sends the bill of services to the designated payer. Usually, the designated payer is the insurance provider. The insurance provider evaluates the claims and determines the services to reimburse.

When the healthcare providers offer the services to the patients, they record the services using the appropriate medical codes. CPT codes apply for various treatments while ICD codes apply for diagnosis. These codes provide a summary of services offered by the provider.

Also, the patient’s insurance information and demographic data are added to the bill. It is after this when the claims get processed.

Who Can Fill Insurance Claims Using the HCFA?

Individual healthcare physicians and not institutions can only fill this form. Below are some of the people who can fill the form;

  • Clinical psychologists
  • Nurse practitioners
  • Physician practitioners
  • Ambulance services
  • Diagnostic laboratory services
  • Nurse Midwives
  • Physician assistants
  • Certified nurse anesthetics
  • Clinical social workers

Only non-institutional healthcare providers should submit insurance claims using the HCFA form. Institutional providers should submit applications using the UB-04 form.

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Filling the Claims

HCFA medical billing Form 2019For the insurance claims to be met, some set industry standard and protocols have to be met. The medical billers use software to record patient data, prepare the claims, and submit to the appropriate insurance provider. However, there is no universal software that the biller must use.

All insurance billing software uses a set of standards set by the HIPAA and the Code Set Rule (TCS). The insurance claims can be filled manually on paper or electronically. Many healthcare providers prefer the electronic system to the manual one.

The electronic system is faster and more accurate compared to the manual one. However, the medical provider should be well versed with both methods.

Rules for Filling the HCFA Form

The HCFA form should be filled according to the provisions of the law. The claims can be rejected if the form is not correctly filled. You can avoid rejection of the claims by doing the following;

  • Fill all data accurately and precisely in the specific fields
  • Use the address for the service facility
  • Include NPI information where required
  • Use the correct procedure and diagnosis codes
  • Enter the patient’s insurance information

The insurance providers need accurate data.

How to Fill the HCFA Form

How the biller fills the HCFA form determines whether or not the insurance provider will offer compensation. The HCFA has 33 boxes that you must fill. Below is a detailed guide on how to fill each detail

1. Type of Payer

In this part, you mark the type of health insurance coverage, i.e. Medicare or Medicaid. Also, enter the patients’ insurance number.

2. Patient’s Name and Gender

Enter the full patient’s name, as shown in the Medicare Card. This section allows entry of up to 28 characters.

3. Birthdate

In this box, the medical provider should include the patient’s date of birth and gender. Use the 6-digit or 8-digit format.

4. Name of the Insured

Enter the name of the insured if not the patient. It can be spouse employment or any other primary. Leave blank if the patient is the one insured.

5. Physical Address

Enter the patient’s address and zip code. The first line is for street address, city, and state on the second line and zip code on the third line.

6. Patient’s relation to the insured

Mark one box showing the relationship of the insured, whether spouse, child, etc. Mark the corresponding on the form.

7. Insured’s address

Enter the insured’s city, state, zip code, phone number, and address. If unknown, leave the physical address details blank. Use employer’s address for worker’s compensation.

8. Patient Status

Fill the general status of the patient. Status includes; worker, student, employed, and marital status.

9. Other Insured’s Details

Include there exists additional health coverage for the insured, add in this column. That consists of the extra health coverage details, personal details, employers detail, school, etc.

10. Reserved for Local Use

This part is preserved for Medicaid information. Enter the patient’s Medicaid number if available.

11. FECA Number/Insured’s Policy Group

Input the insured’s group number or policy as written in the ID card. This proves that the physician made an effort of determining whether it’s primary or secondary Medicare.

12. Patient’s Signature

The patient should sign on the file. If the patient is debilitated, then an authorized representative should sign or enter a 6-digit/8-digit alphanumeric date. If a representative signs, the reasons should be indicated on the line followed by the representative’s relationship and personal details.

13. Insured’s Signature

If the Medigap info is included in section 9, the insured is supposed to authorize the payment by signing in this section. A signature on file is the most appropriate for this section.

14. Date of Illness

When did the patient get ill? The biller should enter the exact date of illness, pregnancy, or illness.

15. Other Dates

Fill this information if the box 10b and 10c are checked. Use a 6-digit or 8-digit to enter the date of a related patient’s condition.

16. Date of Incapacitation

In this section, enter the date in which the patient was unable to work in the current occupation. This section applies if the patient is unemployed but unable to work.

17. Name of Referring Physician

This section applies if another physician referred the patient. Enter the full names, ID number, and NPI number of the referrer.

18. Hospitalization Dates

If the patient was hospitalized, enter the date of hospitalization. You could leave blank if there was no hospitalization needed.

19. Additional Claim Information

The biller should enter the date when the physician’s NPI saw the patient. The payer assigns the identifier to identify the provider uniquely.

20. Outside Lab Charges

The biller should fill this section when billing for diagnostic tests. Mark ‘yes’ if another party other than the provider is offering the service.

21. Patient’s Diagnosis Condition

All health providers, except ambulance services, should enter a patient’s diagnosis specificity using special codes. The codes should be accurate and correct.

22. Medicare Resubmission Code

Enter the original reference number in case of resubmitted claims. This section does not apply for original claim submission. Leave this section blank for Medicare

23. Prior Authorization Number

If the medical procedures require QIO approval, enter the QIO prior authorization number. If an investigational device, enter the 7-digit IDE number. For ambulance services, provide the 5-digit zip code of pickup point.

24. Details of Service

In this section, the biller should include the following;

  • Dates of service
  • Place of service
  • Services or procedures
  • Charge amount
  • Diagnosis Pointer
  • Units/days of service

The above sections do not apply for pneumococcal or influenza vaccine.

25. Federal Tax ID Number

Enter the details of the provider of service (EIN or SSN). This is the unique number used for reporting taxes.

26. Patient’s Account Number

Enter the patient’s number provided by the service provider. This part is not mandatory as it helps the provider to identify the patient.

27. Accept Assignment

Tick the appropriate box to agree to the assignment benefits. Assignment benefits include the following;

  • Supplier/physician services
  • Laboratory services
  • Surgical services
  • Ambulance services

Be sure to select options that only apply to your case.

28. Total Charge of services

The biller should enter the charge of services. Insurance providers require realistic and unexaggerated charges.

29. Amount Paid

The biller should enter the amount paid for the covered services. This does not include discounts.

30. Balance Due

Leave this section plank. Medicare does not need you to fill this section.

31. Signature of the Healthcare Provider

The physician or non-physician offering the service should enter a signature file. The current dates should follow the provider’s signature.

32. Facility Zip Code

Enter the location of the physician’s facility zip code. This applies for services payable under the provider’s fee schedule.

33. Billing Provider NPI and Taxonomy

The biller should enter the facility’s NPI. In this section, the biller should enter their name, address, zip code, and phone number. This is the final section and identifies that the provider is requesting payment for the rendered services.

The Bottom Line

As evident in the above, filling the HCFA form is not an easy task. Inexperienced health care providers should ask for professional medical billing help to avoid messing up and missing out on claims.

If you’re looking for medical billing services, be sure to get quotes for a better comparison.

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Author: Mike Cynar

Mike Cynar brings buyers and sellers together by producing reviews and creating non biased webpages allowing users to share their experiences on various products and services. He and his staff write informative articles related to the medical field, legal, and other small business industries.

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