What are the two types of claim submission?

In argumentative writing and critical thinking, claims generally fall into three main types: claims of fact, claims of value, and claims of policy.

1. Claims of Fact

• What it does: Asserts that something is true or false, existed or does not exist, or will happen in the future.
• How to prove it: Requires empirical data, research, observation, or verifiable evidence.
• Example: "Global warming is accelerated by human activities."
• Learn more about the framework in this Claims of Fact, Value, and Policy Guide.

2. Claims of Value

• What it does: Makes a qualitative judgment about whether something is good, bad, moral, right, wrong, or better than something else.
• How to prove it: Relies on standards, beliefs, ethics, or aesthetic values rather than purely measurable data.
• Example: "Snowboarding is the greatest way to spend a vacation."
• Review foundational writing concepts with College Writing Types of Claims.

3. Claims of Policy

• What it does: Proposes a specific action or solution to a problem, often arguing what should or must be done.
• How to prove it: Combines facts and values to show that a specific rule, law, or behavior needs to change.
• Example: "An individual must be at least 18 years old to apply for a driver's license."

Claim forms are standardized documents used to request payment or reimbursement from an insurance company or program.

The most common types are used in healthcare and insurance, split by electronic and paper formats:

Medical and Healthcare Claim Forms

• CMS-1500 (Paper) / 837P (Electronic): Used by individual doctors, therapists, chiropractors, and outpatient clinics for professional services.
• UB-04 / CMS-1450 (Paper) / 837I (Electronic): Used by institutional facilities like hospitals, skilled nursing facilities, and ambulatory surgery centers.
• ADA Dental Claim Form / 837D (Electronic): Used by dentists for dental procedures using CDT tooth and surface codes.
• NCPDP Universal Claim Form: Used by pharmacies for real-time prescription drug billing.

Other Insurance Claim Forms

• Life Insurance Claim Form: Used by beneficiaries to claim a payout after an insured person passes away.
• Disability or Workers' Compensation Form: Used to request wage replacement or medical coverage for work-related injuries or disabling conditions.
• Property and Casualty Claim Form: Used for auto, home, or business damage after an accident, fire, or theft.

The two primary types of healthcare claims submitted for reimbursement are professional claims and institutional claims.

Professional Claims

• Definition: Bills submitted by individual practitioners or group practices for non-facility services.
• Used For: Office visits, doctor consultations, outpatient treatments, surgeries, therapy sessions, and diagnostic tests.
• Formats: Submitted on the CMS-1500 paper form or electronically as the 837P transaction format.
• Coding Systems: Uses CPT and HCPCS codes for procedures and ICD codes for diagnoses.

Institutional Claims

• Definition: Bills submitted by facilities and healthcare organizations for facility-related and inpatient services.
• Used For: Inpatient hospital stays, emergency room visits, skilled nursing facility care, and room and board charges.
• Formats: Submitted on the UB-04 (also known as CMS-1450) paper form or electronically as the 837I transaction format.
• Coding Systems: Uses revenue codes, ICD-10 diagnosis codes, and Diagnosis Related Group (DRG) codes.

For professional health insurance claims, the standardized paper format is the CMS-1500 Health Insurance Claim Form, while electronic submissions use the ANSI X12 837P format. Other types of insurance (like property, auto, or general liability) do not use a universal standard form and instead require specific loss reports provided directly by individual carriers.

Key Sections of a Standard Medical Claim Form (CMS-1500)

• Patient & Insured Demographics (Top Section): Captures the patient’s full name, address, date of birth, sex, relationship to the insured, and primary/secondary policy numbers (Boxes 1–13).
• Clinical & Service Data (Middle Section): Details diagnosis codes (ICD-10) and itemized procedure codes (CPT/HCPCS) along with dates and places of service (Boxes 14–24).
• Provider Information (Bottom Section): Lists total charges, the provider's National Provider Identifier (NPI), federal tax ID, and service location details (Boxes 25–33).

General & Property Claims Format

• Policyholder Details: Name, contact info, and policy number.
• Incident Details: Exact date, time, and location of the loss or damage.
• Narrative Description: A clear explanation of how the event or damage occurred.
• Supporting Evidence: Itemized repair estimates, photographs, receipts, or police reports.

The standard form used by healthcare providers to submit professional medical claims to insurance companies and government programs like Medicare is called the CMS-1500 form (historically known as the HCFA-1500).

Key Details About the CMS-1500

• Purpose: It is used by non-institutional providers, doctors, and suppliers to bill for outpatient services, professional medical charges, and treatments.
• Design: Maintained by the National Uniform Claim Committee, the form features 33 distinct boxes capturing patient demographics, diagnosis codes, and procedures rendered.
• Alternatives: For institutional providers like hospitals, a different standard form called the UB-04 (or CMS-1450) is used instead.