Insurance Claims and the CMS Form Types of Claims

1. 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

2. 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.

3. Places of service: • 11 office • 12 home • 21 Inpatient Hospitalization • 22 Outpatient Hospitalization • 23 ER-Hospital • 24 Ambulatory Surgical Center

4. 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

5. 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

6. 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

7. 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