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Insurance Claims and the CMS Form Types of Claims

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Insurance Claims and the CMS Form Types of Claims - PowerPoint PPT Presentation


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Insurance Claims and the CMS Form Types of Claims Paper Claim; submitted on paper via fax or regular mail Electronic Claim; send via modem through clearing house Digital Fax; send via fax through computer-never on paper Problem Claims

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Presentation Transcript
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Insurance Claims and the CMS Form

Types of Claims

Paper Claim; submitted on paper via fax or regular mail

Electronic Claim; send via modem through clearing house

Digital Fax; send via fax through computer-never on paper

Problem Claims

Dingy Claim; held by Medicare when claim cannot be processed for service or bill type

Dirty Claim; has errors or needs problems resolved. May be classified as “pending”.

Rejected Claim; due to above and/or requires investigation for further clarification. Should always be resubmitted

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Incomplete claim; missing information
  • Invalid claim; illogical or incorrect (wrong provider numbers, etc)

Note: Clean Claims contain all necessary information and can be processed and paid promptly.

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Places of service:
    • 11 office
    • 12 home
    • 21 Inpatient Hospitalization
    • 22 Outpatient Hospitalization
    • 23 ER-Hospital
    • 24 Ambulatory Surgical Center
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EOB’s (Explanation of Benefits)

Tell:

Patient’s name and policy number

Provider of services

Dates of services

Date claim received

Services or procedures

Amount billed by MD

Amount allowed/disallowed by insurance carrier

Less deductible amount

Co-payment/coinsurance due from patient

Totals paid by insurance carrier

Comments

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Claim Management
    • Insurance claims register-pending file if submitting via paper
    • Insurance payment history-if submitting via paper
  • Types of Common Problems
    • Delinquencies-Payments overdue
    • Pending/suspense claims-still in review
    • Lost claims
    • Rejected
      • Transposed numbers
      • Missing, invalid or incorrect codes/modifiers
      • Missing provider, provider ID#, referring provider
      • Incorrect dates of service
      • Code descriptors that do not match
      • Duplicate dates or charges
    • Denied due to medical coverage policy issues or program issues
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Downcoding

Happens when insufficient diagnostic information is on claim and/or when coding for lesser services than were performed

  • Upcoding

Happens when coding higher for services than what was performed

  • Partial payment

Resubmit

  • Payment made to patient-collect
  • Over payment-deposit and send refund to insurance company
  • Rebilling-q 30 days
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Claim Inquiries

Submit tracers for:

    • payments not received in timely manner
    • investigation under way
    • amount received wrong
    • patient’s responsibility not clearly defined
    • wrong patient/right office
    • code different than was submitted
    • service stated as disallowed
    • error on EOB
    • check made out to wrong MD
  • Appeals-send letters, call insurance company
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