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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.

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Chapter 4

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  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

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