New York Codes, Rules and Regulations › Title 11 - INSURANCE › Appendices › Appendix 18-A

Current through Register Vol. 46, No. 28, July 10, 2024
(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.
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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.
I. D.
(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.