Unit 2: Lesson 4: Verification of Insurance

Demographic Info

• patient Identification

• DOB

• SSN

• Contact info

• Employment details

• Health ins. info

• Primary insured info

• Guarantor info

  • Minors: parent info: name, address, phone #

Insurance Verification

• Confirming insurance coverage and benefits before getting services

• See if preauth is needed

  • see if covered, what is included, costs they have to pay

Ways to Verify and what is needed

Verification through: phone, online portal, EDI system

Need: Health insurance ID number, date of birth, co-pay, covered benefits

Coordination of benefits (COB)

• Determines primary and secondary insurance who pays first

• Avoid duplicate payments, underpayments, and over payments

  • make sure 3rd party don’t go over 100% allowed

COB Rules

• Employer insurance pays 1st

  • parent w/ 1st bday on calendar pays primary

Coordination of Benefits (COB)

• used to find order of 3rd payer coverage when more than 1 insurance plan

Tricare + Medicare

Medicare pays 1st

Tricare 2nd

• Tricare pays Medicare coinsurance

  • patient pays nothing

Medicare + employer insurance

Employer ALWAYS 1ST

Medicare 2nd

Medicar Crossover

• Medicare automatically forward a process claim to the secondary insurance

  • transaction needs to be noted on remittance advice (RA)

Medi-Medi

• Eligible for both Medicare and medicaid

  • Medi-Medi beneficiary

Medical Necessity

• Service, procedure, test, or supply is reasonable, necessary, and appropriate

  • Needed for insurance to pay

Preauthorization/precertification

• needed b4 service/procedure

• hospital stay/ inpatient: # of days

• PT/ outpatient: # of treatment days allowed

Coverage Predetermination

• asking insurance B4 if service is covered & costs

• Dental insurance

• Usually, experimental, investigational, or cosmetic

Tertiary Care Referral

• Referred by a specialist to highly specialized medical facility or another specialist for advanced care

Advanced Beneficiary Notice (ABN)

• Written notice provider gives to Medicare patient b4 service of what may not B covered

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• What may/may not be covered

• Why Medicare won’t pay

• Est of patient cost

• signature req to accept cost

Timely Filing

• deadline set by insurance payer to submit claim

• starts from DATE OF SERVICE (DOS)

• can deny payment

Filing Limits

Medicare/Tricare: 1 year from DOS

Medicare: varies by state, 6 months CA

Commerical/private: 90 days to 1yr depend on policy

Workers Comp & auto: vary by state & payer