Insurance Claims and the CMS Form Types of Claims Types of Claims Paper Claim; submitted on paper via fax or regular mail Paper Claim; submitted on paper via fax or regular mail Electronic Claim; send via modem through clearing house Electronic Claim; send via modem through clearing house Digital Fax; send via fax through computer-never on paper Digital Fax; send via fax through computer-never on paper Problem Claims Problem Claims Dingy Claim; held by Medicare when claim cannot be processed for service or bill type Dingy Claim; held by Medicare when claim cannot be processed for service or bill type Dirty Claim; has errors or needs problems resolved. May be classified as “pending”. Dirty Claim; has errors or needs problems resolved. May be classified as “pending”. Rejected Claim; due to above and/or requires investigation for further clarification. Should always be resubmitted Rejected Claim; due to above and/or requires investigation for further clarification. Should always be resubmitted

Incomplete claim; missing information Incomplete claim; missing information Invalid claim; illogical or incorrect (wrong provider numbers, etc) Invalid claim; illogical or incorrect (wrong provider numbers, etc) Note: Clean Claims contain all necessary information and can be processed and paid promptly.

Places of service: Places of service: 11 office 11 office 12 home 12 home 21 Inpatient Hospitalization 21 Inpatient Hospitalization 22 Outpatient Hospitalization 22 Outpatient Hospitalization 23 ER-Hospital 23 ER-Hospital 24 Ambulatory Surgical Center 24 Ambulatory Surgical Center

EOB’s (Explanation of Benefits) Tell: Patient’s name and policy number Provider of services Dates of services Date claim received Services or procedures Amount billed by MD Amount allowed/disallowed by insurance carrier Less deductible amount Co-payment/coinsurance due from patient Totals paid by insurance carrier Comments

Claim Management Claim Management Insurance claims register-pending file if submitting via paper Insurance claims register-pending file if submitting via paper Insurance payment history-if submitting via paper Insurance payment history-if submitting via paper Types of Common Problems Types of Common Problems Delinquencies-Payments overdue Delinquencies-Payments overdue Pending/suspense claims-still in review Pending/suspense claims-still in review Lost claims Lost claims Rejected Rejected Transposed numbers Transposed numbers Missing, invalid or incorrect codes/modifiers Missing, invalid or incorrect codes/modifiers Missing provider, provider ID#, referring provider Missing provider, provider ID#, referring provider Incorrect dates of service Incorrect dates of service Code descriptors that do not match Code descriptors that do not match Duplicate dates or charges Duplicate dates or charges Denied due to medical coverage policy issues or program issues Denied due to medical coverage policy issues or program issues

Downcoding Downcoding Happens when insufficient diagnostic information is on claim and/or when coding for lesser services than were performed Upcoding Upcoding Happens when coding higher for services than what was performed Partial payment Partial paymentResubmit Payment made to patient-collect Payment made to patient-collect Over payment-deposit and send refund to insurance company Over payment-deposit and send refund to insurance company Rebilling-q 30 days Rebilling-q 30 days

Claim Inquiries Claim Inquiries Submit tracers for: payments not received in timely manner payments not received in timely manner investigation under way investigation under way amount received wrong amount received wrong patient’s responsibility not clearly defined patient’s responsibility not clearly defined wrong patient/right office wrong patient/right office code different than was submitted code different than was submitted service stated as disallowed service stated as disallowed error on EOB error on EOB check made out to wrong MD check made out to wrong MD Appeals-send letters, call insurance company Appeals-send letters, call insurance company