1 / 28

Chapter 4

Chapter 4. Life Cycle of an Insurance Claim. Development of an Insurance Claim. CMS-1500 claim is used to report professional and technical services Patient encounter form (or Superbill) is used to generate the provider’s claim for payment. Life Cycle of an Insurance Claim.

alvin-sears
Download Presentation

Chapter 4

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Chapter 4 Life Cycle of an Insurance Claim

  2. Development of an Insurance Claim • CMS-1500 claim is used to report professional and technical services • Patient encounter form (or Superbill) is used to generate the provider’s claim for payment

  3. Life Cycle of an Insurance Claim

  4. Information to Claim • Information from the Superbill, patient record, or chart is then transferred to the CMS-1500 claim

  5. Accepting Assignment • When provider agrees to what the insurance company allows and or approves as payment

  6. Accepting Assignment • CMS-1500 claim: • Requires responses pertaining to patient’s condition and if related to employment, auto or any other accident, additional insurance coverage, or use of an outside laboratory.

  7. Accepting Assignment • Patient is responsible for co-payment and coinsurance amounts • “Signature on File” can be used as a substitute for patient’s signature, as long as real signature is on file.

  8. Accepting Assignment • Claim is proofread and double checked • Any supporting documents are copied from patient’s chart and attached to claim

  9. Managing New Patients • Office policy and procedures (paying co-payments) • Should be explained and posted at receptionist desk • Determine whether appropriate office has been contacted • Then preregister new patients

  10. Managing New Patients • Patient must complete a patient registration form upon arrival • Make photocopy (front and back) of patient’s insurance card • File in patient’s financial record

  11. Managing New Patients • Contact payer • Confirm patient’s insurance information located on back of insurance card • Verify information with patient and/or subscriber • Make changes • Enter information using computer entry software

  12. Managing New Patients • Create a new medical record for the patient • Generate patient’s encounter form • Encounter form is a financial record that documents treated diagnoses and services

  13. Managing Established Patients • Schedule a return appointment when patient is checking out or when patient calls office • Verify all registration information • Encounter form needs to be generated for patient’s current visit

  14. Managing Office Finances • CPT and HCPCS level 2 (national) codes are assigned to procedures • Enter charges for services and/or procedures • Post charges to patient’s account • Collect payment from patient

  15. Managing Office Finances • Post payment to patient’s account • Complete insurance claim • Attach documents that support the claim • Obtain provider’s signature on claim if processed manually

  16. Managing Office Finances • File copies of the claim and attachments in the practice’s insurance files • Log completed claims in an insurance registry • Send claims by mail or electronically

  17. Appealing Denied Claims • Remittance advice indicates that the payment was denied for reasons other than a processing error

  18. Steps to Appeal Denial • Procedure or services should be reviewed from original documents for diagnostic supporting documentation • Research procedure and patient documentation when denied for “medical necessity.”

  19. Steps to Appeal Denial • Determine if condition is pre-existing • If incorrect diagnosis code was submitted on original claim • Correct claim and resubmit

  20. Steps to Appeal Denial • Noncovered benefit • Determine if treatment submitted was excluded • If incorrect procedure code was submitted • Correct claim, resubmit, and attach copy of medical record documentation to support code change

  21. Steps to Appeal Denial • Termination of coverage • Contact patient • Determine current coverage • Authorization should be performed prior to service • If this was performed, submit with authorization number

  22. Steps to Appeal Denial • Failure to obtain preauthorization requests is a costly error for practice • Retrospective review of claims are more difficult or sometimes impossible to obtain

  23. Steps to Appeal Denial 6. Out of network providers • Write letter of appeal explaining why treatment was sought outside the provider network

  24. Steps to Appeal Denial • Provide letter of appeal explaining why higher level of care was required • Copies of patient’s chart may be needed for review by insurance adjudicator.

  25. Credit and Collections • Delinquent claims and prevention • Verify health insurance cards • Determine each patient’s coverage • Electronically submit a clean claim

  26. Credit and Collections • Contact payer to verify received claim • Review records to determine if claim is paid, denied, or pending • Submit supporting documents

  27. Claim Submission Problems, Descriptions, and Resolutions • Coding errors • Delinquent • Denied • Lost

  28. Claim Submission Problems, Descriptions, and Resolutions • Overpayment • Payment errors • Pending • Suspense • Rejected

More Related