The reverse of the CMS-1500 claim contains special instructions for government programs.
claims are usually submitted electronically to a third party clearinghouse or payer, except when paper claims are permitted using a computer with software that meets electronic filing requirements stablished by HIPAA health insurance portability and accountability Act.
the claim is electronically transmitted as data packets.
upon receipt of data packets a series of edits is conducted to determine whether the claims meet the basic of the HIPAA administrative simplification standard.
any errors at this stage results in rejection of the entire data packet.
claims that pass the initial edits are next edited agains HIPAA claim standards implementation guide requirements.
after passing the first 2 initial edits each claim is reviewed for compliance with coverage and payment policy requirements.
Rejected data packets and individual claims are returned to the submitter ( Provider, billing company, clearinghouse.
Denied claims may initiate the appeals process.
upon successful transmission, an acknowledgment report is generated and transmitted to the submitter of each claim.
electronic claims must meet requirements adopted as the National standard under HIPAA