What Every Claim Needs

One of the first questions I get asked when contacted by a new patient is, “what will I need to get paid.” The initial patient encounter is where you would make sure that you have everything that is needed to move from visit to billing to payment. Having everything you need, before the patient leaves the office, helps to create that clean claim that should be processed quickly and accurately by the health insurance carrier.  

How To Ensure You Have Everything You Need To Get This Claim Paid

Step One - Although the patient may have provided enough information to secure a spot on the calendar, once they are in the office we need the hardcopy information that is needed to create a file for the patient and start the process. This includes:

The Information

  • Plan type: Medicare, Medicaid, Tricare, Group plan, other
  • The patient demographics: name, age, date of birth, address, phone number.
  • The health carrier information, such as relationship to patient, plan holder name and date of birth, employer name and address, group numbers and correct ID numbers.
  • If other coverage exists and if so the complete plan name, address, and ID numbers of any secondary or tertiary carrier.
  • If the condition is related to an injury, or is work related.
  • Referring provider name and NPI information.
  • Correct ICD indicator (ICD-9 or ICD-10)
  • The correct ICD-10, CPT, and/or HCPCS coding and the correct charges.
  • Correct provider of service information. Including correct provider numbers, NPI and service location.
  • Patient's "signature on file" authorizing release of information and authorizing the insurance carrier to pay either the patient or the provider directly.
  • Correct place of service code.
  • Correct Prior Authorization number.
  • Correct dates of service.
  • Correct charge for each service
  • Correct number of items or units
  • Correct modifier if needed.
  • All supporting information including: operative reports, letters of medical necessity, primary carrier's EOB’s, invoices, etc. (The time it takes for the carrier to request additional information and for you to respond may take months.)

Step Two - Now that we have the plan information, step two is all about turning this piece of paper into a positive confirmation of coverage. This will then allow you to take this from a billed charge to a fully paid claim.  


The Process

  •  Call the health carrier to verify benefits and eligibility on all new patients, every time. For returning patients, call again if it has been more than a month.   
  • Collect all amounts deemed to be a patient’s portion upfront.  
  • Secure needed referral or preapprovals on all required services, treatments and supplies. Make sure you have this as a hardcopy not just verbally.
  • Always code to the highest level of specificity. Especially with the new ICD-10 codes that were expanded to include a wider ranges of codes to choose from. Make sure that the person that is responsible for pre-coding all claims is not just cross walking from the old ICD-9 code to the exact same ICD-10 code. Coders should be taking the time to review the new ICD-10 manual to select the exact code/s that best fits the claim.
  • Set yourself up to bill claims electronically whenever possible. Most health carriers have an enrollment process that, once completed, will allow you to bill electronically and also receive electronic (EFT) payments and online EOB’s and Remittance Advices.
  • A signed ABN form for all Medicare beneficiaries for service, supplies or treatment that may not be paid by Medicare. Do not accept the patient’s assurance that they understand a service may not be covered. Failure to have a signed ABN will work in the patient’s favor and you may be required to refund back any monies collected.

Finally, never assume that the carrier has all of the information on file, the responsibility is on the biller to get it right not on the claim payer to piece your billed claim together.

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