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| 14793468201 | Medical Billing Process | Collect as much patient information as possible regarding insurance coverage and payment expectations of the patient when the patient makes the appointment. Make a copy of the patient's insurance card and a government-issued photo ID at the time of the appointment. Remember to update the copies of insurance cards once a year. Once the patient's copayment responsibility is determined, collect the copayment before any medical services are provided. Verify the patient's coverage and eligibility prior to the appointment. Contact the provider services department or check online to confirm if the patient's contract with the insurance company is valid for the date of service. Contact the health insurance company's representative to request for precertification, if needed. In some instances, precertification is required in order for any payment to be authorized prior to medical services being provided. Code the diagnosis or procedure appropriately after medical services are provided. This coding information is provided to the insurer. Complete and submit the insurance claim form. Most insurance companies have an electronic claim form that is submitted online. Ensure accuracy during the billing process by reviewing the claims submission report. | 0 | |
| 14793468202 | Patient's Financial Responsibilities to Third Party | Copayment Deductible Out of Pocket Costs Coinsurance | 1 | |
| 14793468203 | CMS-1500 Form | Universal claim form used by most insurance providers to authorize payment for services. The MA can fill out the paper form or the electronic claim form depending upon the insurance company's policies. The information to be filled in an electronic claim form is identical to the information filled in the paper form and is divided into three sections. | 2 | |
| 14793468204 | CMS-1500 Section I | This section indicates the type of insurance, insurance address, and insurance number. | 3 | |
| 14793468205 | CMS-1500 Section II | This section includes patient and insured information. This is to specify which person is covered by the plan and how they are related to the insured. | 4 | |
| 14793468206 | CMS-1500 Section III | This section includes physician or supplier information. This information is about the service provider, services provided, and the medical conditions being treated. | 5 | |
| 14793468207 | When should the copayment be collected? | Before medical services are provided | 6 | |
| 14793468208 | How is patient eligibility confirmed? | Contacting the provider services department to confirm that the patient's contract with the insurance company is valid for the date of service | 7 | |
| 14793468209 | Direct Billing | the submission of electronic claims directly to the insurer. In the initial insurance claim, only basic patient information is provided to the insurance company, including patient name, date of birth, and insurance ID number. Diagnostic and procedural information is also sent. Transmitter IDs do not need to be included, as they are identifiers that are already part of the billing system. | 8 | |
| 14793468210 | Carrier direct Billing | When physician's office or other medical office sends a claim directly to the medical insurance carrier. Major insurance companies-like Medicare, Medicaid, Aetna, and Cigna-provide billing software to the provider or office at no cost. It is simple and supplies required information, but is limited in that information can only be supplied to specific carriers, such as Medicare or Medicaid. This type of billing cannot be used for multiple third-party payers. | 9 | |
| 14793468211 | Sending an Electronic Claim Form | When an electronic claim is sent, the MA should monitor processing and look for communication from the insurer. The insurer may request additional information, and the MA should address these requests as soon as possible. Delays in fulfilling requests may mean delays in payment. Further information may include progress notes or notes made by the provider about treatment provided. If this information is delayed, reimbursement to the provider may be suspended or withheld. The MA should always work to complete the electronic forms with a very high level of attention to detail and accuracy. Forms that are submitted with errors will delay payment or even lead to denial of benefits. Electronic submission should be reviewed for accuracy, and denials should be checked closely. | 10 | |
| 14793468212 | Clearinghouse Services | Services provided by clearinghouses include: Auditing claims for accuracy. This helps in identifying errors and ensuring completeness, which in turn expedites payment and reduces the instances of denied claims. Generating statistical reports on the total number of claims, as well as the number of errors in a submission. Forwarding claims to other clearinghouses that may have contracts. This means that if the claim is submitted once, it does not need to be resubmitted to a different insurer. This can be helpful if the patient has more than one insurance carrier. Keeping medical offices informed of new insurance carriers added to the database. Providing reports on the number of claims submitted to third-party payers as well as the number of errors and their specifics. For example, a provider may want to see how many claims have been submitted to Blue Cross. | 11 |
