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This chapter provides an in-depth look at completing fee-for-service claims for commercial insurance. It includes separate instructions for primary, secondary, and supplemental insurance plans, formatted in a clear table for easy understanding. A detailed case study along with a completed claim serves as a practical illustration of the instructions. Students will practice with provided claims, allowing them to receive constructive feedback. Additionally, criteria for determining coverage situations are thoroughly explained to aid in processing claims effectively.
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Chapter 12 Commercial Insurance
Introduction • This chapter is going to be talking about how to complete fee-for-service claims
Processing Commercial Claims • Separate instructions for primary, secondary, and supplemental commercial insurance plans. • Instructions in a table format for completing claims.
Processing Commercial Claims • A case study and completed claim to illustrate the instructions • Give a plain and a completed claim to the students to practice completing a claim • Completed claims allow the students to receive feedback
Commercial Claims • Determined by one of the following criteria: • Patient is covered by one commercial plan • Patient is covered by a large employer group health plan and also Medicare beneficiary • Patient is covered by a small or large employer health plan and is the policy holder • Patient is also listed as a dependent on another EGHP
Commercial Claims • Determined by one of the following criteria: • When the patient is a child who is covered by two or more plans • Primary policyholder is the parent whose birthday occurs first in the year
Commercial Secondary Coverage • Changes are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health insurance plans.
