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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Insurance Claims and the CMS Form Types of Claims

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Insurance claims and the cms form types of claims

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


Insurance claims and the cms form types of claims

  • 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.


Insurance claims and the cms form types of claims

  • Places of service:

    • 11 office

    • 12 home

    • 21 Inpatient Hospitalization

    • 22 Outpatient Hospitalization

    • 23 ER-Hospital

    • 24 Ambulatory Surgical Center


Insurance claims and the cms form types of claims

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


Insurance claims and the cms form types of claims

  • 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


Insurance claims and the cms form types of claims

  • 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


Insurance claims and the cms form types of claims

  • 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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