Chapter 4
- 1. Life Cycle of an Insurance Claim Chapter 4
- 2. Processing an Insurance Claim CMS-1500 claim is used to report professional and technical services. Information from the Superbill, patient record, or chart is then transferred to the CMS-1500 claim.
- 3. Accepting Assignment When provider agrees to what the insurance company allows and or approves as payment Patient is responsible for copayment and coinsurance amounts. “ Signature on File” can be used as a substitute for patient’s signature, as long as real signature is on file.
- 4. Assignment of Benefits Patient or insured authorizes the payer to reimburse the provider directly.
- 5. Accounts Receivable Management Assists providers in the collection of appropriate reimbursement for services rendered
- 6. Managing New Patients Office policies and procedures (paying copayments, appointment rescheduling) Determine whether appropriate office has been contacted Patient must complete a patient registration form upon arrival. Make photocopy (front and back) of patient’s insurance card Contact payer Verify information with patient or subscriber.
- 7. Primary versus Secondary Insurance Primary insurance is plan that is responsible for payment of a claim first. After payment by primary insurer, secondary is billed. Children of divorced parents Child living with both parents, if both have insurance
- 8. Primary versus Secondary Insurance Create a new medical record for the patient. Generate patient’s encounter form. Encounter form is a financial record that documents treated diagnoses and servic es.
- 9. Managing Established Patients Schedule a return appointment when patient is checking out or when patient calls office. Verify all registration information. Collect copayment. Encounter form needs to be generated for patient’s current visit.
- 10. Managing Office Insurance Finances CPT and HCPCS Level II (national) codes are assigned to procedures. Enter charges for services and/or procedures. Post charges to patient’s account .
- 11. Life Cycle of an Insurance Claim
- 12. Claims Submission Electronic or manual transmission of claims data to insurance payers or clearinghouses Public or private entity that processes or facilitates the processing of nonstandard data elements into standard data elements Convert standard transactions (e.g., electronic remittance advice) received from payers to nonstandard formats
- 13. Electronic Claims Submission Electronic Date Interchange – EDI Computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties
- 14. Claims Attachments Medical evaluation for payment Past payment audit or review Quality control to ensure access to care and quality of care
- 15. Claims Processing Sorting claims upon submission to collect and verify information about the patient and provider
- 16. Claims Adjudication Claim is compared to payer edits and patient’s health plan benefits to verify Common data file is an abstract of all recent claims filed on each patient. Allowed charge is the maximum amount an insurer will pay for a service.
- 17. Claims Adjudication Deductible is total amount of covered medical expenses a policyholder must pay each year out of pocket before the insurance company is obligated to pay any benefits. Coinsurance is the percentage that patient pays for covered services after the deductible has been met and the copayment has been paid .
- 18. Payment of a Claim Once adjudication is complete, claim is paid or denied: EOB is sent to patient/policyholder. Remittance advice is sent to provider. Prompt payment laws provide specific timeframes in which claims must be paid .
- 19. Maintaining Claim Files CMS requires claims and copies of attachments to be kept for six years. Open claims Closed claims Remittance advice files Unassigned claims
- 20. Tracking Claims Submissions Effective claims tracking requires the following activities Noncovered service rejections Rejections for errors Noncovered service rejections Rejections for errors
- 21. Appealing Denied Claims Remittance advice indicates that the payment was denied for reasons other than a processing error.
- 22. Credit and Collections Delinquent claims and prevention. Verify health insurance cards. Determine each patient’s coverage. Electronically submit a clean claim. Contact payer to verify received claim. Review records to determine if claim is paid, denied, or pending. Submit supporting documents