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.
To Ensure You Have Everything You Need To Get This Claim Paid
- 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:
type: Medicare, Medicaid, Tricare, Group plan, other
patient demographics: name, age, date of birth, address, phone number.
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.
other coverage exists and if so the complete plan name, address, and ID
numbers of any secondary or tertiary carrier.
the condition is related to an injury, or is work related.
provider name and NPI information.
ICD indicator (ICD-9 or ICD-10)
correct ICD-10, CPT, and/or HCPCS coding and the correct charges.
provider of service information. Including correct provider numbers, NPI
and service location.
"signature on file" authorizing release of information and
authorizing the insurance carrier to pay either the patient or the
place of service code.
Prior Authorization number.
dates of service.
charge for each service
number of items or units
modifier if needed.
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
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
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
all amounts deemed to be a patient’s portion upfront.
needed referral or preapprovals on all required services, treatments and
supplies. Make sure you have this as a hardcopy not just verbally.
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.
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.
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.
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.