Healthcare claims pricing : How to identify claim is Professional( Medical) claim or Institutional ( Facility or Hospital) claim

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Healthcare claims pricing is very complex concept and ever evolving based on the healthcare rules and regulation and very hard to explain .. I am venturing to explains this .

There are 2 types of claims forms provider submits to healthcare payers for reimbursement ( Either paper or Electronic - 837 EDI file)

1. CMS -1500 form - Professional claims or medical claims or 837-P EDI

2. UB-04 form- Institutional claims or facility claims or hospitals claims or 837 -I EDI

How to identify claim is professional or Institutional  : There are many way we can identify claim is professional or Institutional like professional claims will be claimed on CMS-1500 form Institutional claims will be on UB-04 form or 837 EDI will have identification ( ASC X12N 837 (005010X222A1)  for professional and  ASC X12N 837 (005010X223A2) for institutional or SV1 segment for Professional and SV2 segment for institutional claims or Revenue codes will not be there in professional claims and will be there in institutional claims but below one is the most important that I use for claims identification.

Professional claims :

Professional claims will have Place of service(POS)

Institutional claims : 

Institutional claims will have Type of Bill( TOB)

Place of service and Types of Bill are 2 important concepts of claims pricing and I will explain this in details.Also claims will be Inpatient and Outpatient also depends on Place of service( some place of service are inpatient and some are outpatient) and Types of bill ( again some are inpatient and some are outpatient). Emergency or urgent care visit will have different place of service than office visit and so we have different price . In next post I will explain in details about Place of service and why it is important to understand.

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