The CMS-1500 is a Medicare claim form for reimbursement that should be submitted with significant attention to detail and accuracy since many potential issues can lead to claim rejection. One of the reasons to deny the form is a contractual obligation, meaning that the claim lacks some information required for adjudication. For instance, the program certification is not included (Ernzen et al., 2019). Incorrect information, such as an invalid NPI number, can also cause rejection of the CMS-1500 claim (Ernzen et al., 2019). Finally, the form can be rejected if it is associated with incomplete or invalid procedure rates or codes. For example, the service code for the reimbursement program is not part of the organization’s contract (Ernzen et al., 2019). All the reasons described above can lead to the return or complete rejection of a claim, which is why it is necessary to follow the billing guidelines when filling out the CMS-1500 form accurately.
In addition, reviewing the completed claim before submitting it can help ensure that there are no errors leading to denial. The claim may contain the wrong name of the insured person or some incorrect or invalid procedure codes, which can make the form unprocessable. The CMS-1500 claim can also be denied or rejected if the organization does not have proper certifications or is not eligible to bill the patient individually (Ernzen et al., 2019). Thus, producing a clean claim would take three necessary steps: familiarizing with the billing guidelines for a specific program, ensuring that all required procedures and certifications are present, and reviewing the completed form. Following those steps is a key to the successful CMS-1500 claim submission.
Ernzen, M., Pape, A., & Witry, M. (2019). Experience of an Iowa community pharmacist in seeking reimbursement for group diabetes education. J. Iowa Pharm. Assoc, 24-27.