Ch 27 Preparing Insurance Claims and Posting Insurance Payments

CMS-1500 Form

The standard claim form for billing accepted by Medicare, Medicaid, and most other health insurance groups.

Electronic Claims Mandate

Claims must be submitted electronically unless a written waiver has been obtained first.

EDI (Electronic Data Interchange)

The system used for electronic claims filing, which requires completing an enrollment form.

EMC (Electronic Media Claims)

The term for insurance claims that are submitted electronically.

ASCA (Administrative Simplification Compliance Act)

The act that sets forth the specific requirements a provider must meet to be allowed to file paper claims.

Paper Claim Waiver Process

A provider must self-attest or file in writing, prove they meet an ASCA requirement, and obtain approval.

Clearinghouse

A private or public company that acts as a middleman to transmit and translate electronic claims into the specific format required by payers.

Electronic Claims Tracking

The preferred method of tracking because it is more efficient and less time-consuming than manual tracking.

Delinquent Claims

Claims submitted without payment or denial after 3 weeks (electronic) or 6 weeks (paper).

Explanation of Benefits (EOB)

A document sent to the patient showing how an insurance claim was paid on their behalf.

Remittance Advice (RA)

A document sent to the provider by the payer that contains payment information, often for multiple patients and claims.

ERA and EFT

Electronic Remittance Advice and Electronic Funds Transfer; when combined with UB-04 electronic forms, they allow for automated electronic payments.

Practice Management System

The software most commonly used by offices to apply insurance payments and adjustments to patient accounts.

Secondary Insurance Billing

A process similar to primary billing where the secondary payer covers most or all of the balance left by the primary insurance.

What two things should the office claims processor have before processing a patient’s claim?

The claims processor should have a copy of the patient’s insurance coverage card and have secured the

patient’s signature on a form to permit release of information

Explain the differences between electronic and tracking systems.

An electronic tracking system is computerized and allows for quick claims processing, quick electronic transmittals, and quick provider reimbursement turnaround times; whereas manual tracking systems require use of a log with several columns of information; they are time-consuming and frequently cause payment delay

List five pieces of information found on an EOB.

Information found on an EOB includes:

• patient name

• insured ID number

• claim number

• provider name

• type of service

• date of service

• charges

• not covered amount

• total patient cost

• payment made to the patient’s provider

• how much of the annual deductible met by the patient

List four pieces of information to have before calling to follow up on a delinquent insurance claim

Information to have before calling on a delinquent insurance claim includes:

• practice tax ID number

• patient’s name

• ID number

• group name or number

• the insured’s name (if not the patient’s name)