Esi Manual Claim Form
Martta Borromeo
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Submit forms online through the Employees' Compensation Operations and Management Portal (ECOMP). On the ECOMP site you can register for an account, initiate a claim, upload documents, submit forms, and access your case.
OWCP's Federal Employees Program has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation. These forms can be viewed in an Internet Explorer browser window, but not in other browsers. If you are using Chrome or Firefox, follow these instructions to download PDF files and open them in Adobe Acrobat Reader.
All of the Federal Employees Program's online forms (with the exception of Forms CA-16, CA-26 and CA-27) are available to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail or fax the completed form to the Federal Employees Program office you normally send to for this process.
Forms noted with an asterisk (*) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail or fax the completed form to the Federal Employees Program office you normally send to for this process.
NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.
This form is only available to registered medical providers by logging into the OWCP Web Bill Portal. To submit the form, providers must click on the 'Provider' Link to the right of the FECA oval located at the top left of the home page, login with their user ID and password, and then click on the 'LMN Documents' link located in the left menu bar. For providers not yet registered, after clicking the 'Provider' link, click the 'Web Registration' link located in the left menu bar to register for web access. For providers not yet enrolled, click on 'Forms & Links' in the horizontal menu at the top of the home page to download the Provider Enrollment form and instructions.
The NUCC has developed a 1500 Reference Instruction Manual detailing how to complete the claim form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed.
Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020. Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way.
You need to fill out an "Authorization to Disclose Personal Health Information (PDF) if you want someone to be able to call 1-800-MEDICARE on your behalf or you want Medicare to give your personal information to someone other than you.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
To access the sample claim form, click the link and then click "CMS-1450". This will open a folder so you can view the front and the back. UB-04 Sample Claim Form
The Security Health Plan Processing System is designed to process standard health insurance claim forms (UB-04) using Revenue Codes, Health Care Common Procedure Coding System (HCPCS) with appropriate modifiers and ICD-10-CM Diagnosis Codes.
FL4: Type of Bill - The first digit of the three-digit number identifies the type of facility, the second digit classifies the type of care being billed, and the third digit indicates the sequence of the bill for a specific episode of care.
FL62: Insurance Group No. - The identification number, control number or code that is assigned by the insurance company or claims administrator to identify the group under which the individual is covered.
FL67: Principal Diagnosis Code - The full ICD-10-CM diagnosis code, including the fourth and fifth digits, if applicable, that describes the principal diagnosis (the condition established after study to be chiefly responsible for causing the hospitalization or use of other hospital services). Present on admission indicator (POA) should be indicated in the field on the far right following the code.
FL67 A-Q: Other Diagnosis Code - This field contains the full ICD-10-CM diagnosis codes, including the fourth and fifth digits, if applicable, corresponding to all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode that has no bearing on the current hospital stay should be excluded. Present on admission indicator (POA) should be indicated in the field on the far right following the code.
FL74: Principal Procedure Code/Date - The ICD-10-PCS for the principal procedure performed during the period covered by the bill and the date on which the principal procedure described on the bill was performed. For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated.
FL74 A-E: Other procedure codes and dates - This field allows reporting of up to five ICD-10-PCS to identify the significant procedures performed during the billing period, other than the principal procedure, and the corresponding dates when the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. For inpatient and home IV therapy services, if surgery is performed during the inpatient stay from which the course of therapy is initiated. Enter the codes in these fields in descending order of importance.
Security Health Plan uses optical character recognition (OCR) software when processing paper claims. OCR software processes claim forms by reading text within fields on the claim form utilizing scanners to create an image. This software speeds paper claim processing if claim forms are completed correctly. Tips for submitting error-free paper claim submission:
Iowa Medicaid has an online searchable directory of currently enrolled Providers that may order or prescribe durable medical equipment (DME), independent lab services or consultations. Please consult the attached online directory before services or supplies are provided. The online directory is searchable by entering a National Provider Identification (NPI) number and Date of Service.
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote uniform, accurate coding methodologies and to combat improper and abusive coding. The policies are based on conventions defined by the American Medical Association, national societies and analysis of standard practices. The National Correct Coding Initiative (NCCI) Coding Policy Manual is updated annually, with individual edits quarterly. The NCCI Coding Policy Manual should be utilized as a general reference tool that explains the rationale for NCCI edits. In cases where claims processed by Iowa Medicaid (IM) show a "correct coding edit" post on a provider's remittance advice statement, supplemental edit details are available on the Correct Coding Edit Verification Portal by entering the Transaction Control Number (TCN) and billing NPI of the claim.
Effective August 1, 2019, Iowa Medicaid and the Managed Care Organizations (MCOs) implemented a mandatory electronic billing requirement for all Medicaid enrolled providers for both Fee-for-Service (FFS) and Managed Care (MC) claims. This requirement was implemented for Medicaid enrolled dental providers effective February 1, 2020.
Electronic Data Interchange is Iowa Medicaid's clearinghouse for electronic healthcare transactions. In these transactions, providers and Iowa Medicaid exchange information though defined, electronic conventions that support established processes such as eligibility look-up, claim submission and payment information. Iowa Medicaid's portal for these transactions is EDI support services (EDISS). At EDISS, providers identify themselves and enroll for transactions they intend to utilize.