Chapter 4 Life Cycle of an Insurance Claim
- Slides: 28
Chapter 4 Life Cycle of an Insurance Claim Copyright © 2008 Delmar Learning. All rights reserved.
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 2 Copyright © 2008 Delmar Learning. All rights reserved.
Life Cycle of an Insurance Claim 3 Copyright © 2008 Delmar Learning. All rights reserved.
Information to Claim • Information from the Superbill, patient record, or chart is then transferred to the CMS-1500 claim 4 Copyright © 2008 Delmar Learning. All rights reserved.
Accepting Assignment • When provider agrees to what the insurance company allows and or approves as payment 5 Copyright © 2008 Delmar Learning. All rights reserved.
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. 6 Copyright © 2008 Delmar Learning. All rights reserved.
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. 7 Copyright © 2008 Delmar Learning. All rights reserved.
Accepting Assignment • Claim is proofread and double checked – Any supporting documents are copied from patient’s chart and attached to claim 8 Copyright © 2008 Delmar Learning. All rights reserved.
Managing New Patients • Office policy and procedures (paying copayments) – Should be explained and posted at receptionist desk • Determine whether appropriate office has been contacted – Then preregister new patients 9 Copyright © 2008 Delmar Learning. All rights reserved.
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 10 Copyright © 2008 Delmar Learning. All rights reserved.
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 11 Copyright © 2008 Delmar Learning. All rights reserved.
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 12 Copyright © 2008 Delmar Learning. All rights reserved.
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 13 Copyright © 2008 Delmar Learning. All rights reserved.
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 14 Copyright © 2008 Delmar Learning. All rights reserved.
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 15 Copyright © 2008 Delmar Learning. All rights reserved.
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 16 Copyright © 2008 Delmar Learning. All rights reserved.
Appealing Denied Claims • Remittance advice indicates that the payment was denied for reasons other than a processing error 17 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 1. Procedure or services should be reviewed from original documents for diagnostic supporting documentation – Research procedure and patient documentation when denied for “medical necessity. ” 18 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 2. Determine if condition is pre-existing – If incorrect diagnosis code was submitted on original claim • Correct claim and resubmit 19 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 3. 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 20 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 4. Termination of coverage – Contact patient – Determine current coverage – Authorization should be performed prior to service – If this was performed, submit with authorization number 21 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 5. Failure to obtain preauthorization requests is a costly error for practice – Retrospective review of claims are more difficult or sometimes impossible to obtain 22 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 6. Out of network providers – Write letter of appeal explaining why treatment was sought outside the provider network 23 Copyright © 2008 Delmar Learning. All rights reserved.
Steps to Appeal Denial 7. 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. 24 Copyright © 2008 Delmar Learning. All rights reserved.
Credit and Collections • • Delinquent claims and prevention Verify health insurance cards Determine each patient’s coverage Electronically submit a clean claim 25 Copyright © 2008 Delmar Learning. All rights reserved.
Credit and Collections • Contact payer to verify received claim • Review records to determine if claim is paid, denied, or pending • Submit supporting documents 26 Copyright © 2008 Delmar Learning. All rights reserved.
Claim Submission Problems, Descriptions, and Resolutions • • Coding errors Delinquent Denied Lost 27 Copyright © 2008 Delmar Learning. All rights reserved.
Claim Submission Problems, Descriptions, and Resolutions • Overpayment • Payment errors • Pending – Suspense • Rejected 28 Copyright © 2008 Delmar Learning. All rights reserved.
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