Career Development III … · Web viewInstructor Coleman Career Development III Final Portfolio...

Greten Family Practice Handbook125 Wash Road

Somewhere, NY 12457-5689(555) 2647

www.gretenfamilypractice.org

Instructor Coleman

Career Development III

Final Portfolio Submit

Karen Stevens7-31-2017

Name: ______________________________________________________________________________Last First M.I.

Address:_____________________________________________________________________________Street Apt.# City State Zip

Phone #:_________________________ Y N Y NHome Permission To Contact (circle) Permission For Message (circle)

Phone # _________________________ Y N Y NCell Permission To Contact (circle) Permission For Message (circle)

Social Security #___________________ Date of Birth: ________________ Gender: _______________MM/DD/YYYY

Marital Status (Circle): S M D W Single Married Divorced Widowed

Parent/Guardian: (Must be completed if patient is a Minor) Name: ______________________________________________________________________________

Last First M.I.

Address:_____________________________________________________________________________Street Apt.# City State Zip

Phone #:_________________________ Y N Y NHome Permission To Contact (circle) Permission For Message (circle)

Phone # _________________________ Y N Y NCell Permission To Contact (circle) Permission For Message (circle)

Social Security #___________________ Date of Birth: ________________ Gender: _______________

Employment Information: (optional) Employer: _______________________________ Contact: ___________________________________

Spouse / Emergency Contact: Contact Name:___________________________ Phone #: ___________________________________

Relationship to Patient: _____________________________________Y_________N_______________Permission to contact in an emergency (circle)

Nearest Relative Contact:Contact Name:___________________________ Phone #: ___________________________________

Relationship to Patient: _____________________________________Y_________N_______________Permission to contact in an emergency (circle)

Please Turn Form To Next Page And CompletePage 1 of 2

Patient Information

Greten Family Practice125 Wash Road

Somewhere, NY 12457-5689(555) 2647



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Patient Insurance Information

Primary Insurance____________________________________________________________________________Policy Holder: _______________________________________________________________________

Name (Last, First, M.I) Phone #

Address: ___________________________________________________________________________Street Apt.# City State Zip

D.O.B (MM/DD/YYYY):____________________Relationship To Patient ___________________________

Employer: _______________________________ Social Security # ____________________________

Insurance Information:Insurance Company: ______________________ Plan Name: _______________________________

Group #: __________________ Plan #: ______________________ Effective Date: ____________

Secondary Insurance____________________________________________________________________________Policy Holder: _______________________________________________________________________

Name (Last, First, M.I) Phone #

Address: ___________________________________________________________________________Street Apt.# City State Zip

D.O.B (MM/DD/YYYY):____________________Relationship To Patient ___________________________

Employer: _______________________________ Social Security # ____________________________

Insurance Information:Insurance Company: ______________________ Plan Name: _______________________________

Group #: __________________ Plan #: ______________________ Effective Date: ____________

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Consent:

I voluntarily consent to any and all health care treatment and diagnosis procedures provided by Greten Family Practice and its’ medical professionals. I understand that no guarantee can be made as to results of treatment/ examination.

_____(Signature)_____________________-____________(date)_______

I authorize and request assignment of benefits to be paid from my insurance directly to Greten Family Practice. I understand that the amount totals are estimates and will not receive exact amount owed until insurance has paid. I understand that finances rendered from service are my responsibility. I further accept responsibility of all balances not paid by the insurance company.

______(Signature)___________-________(date)_____


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Patient HIPAA Authorization FormNotice describes how medical information about you can be used/disclosed and how you can access

your health information. READ CAREFULLY.Patient Health Information (PHI)Under federal law, your patient health information is confidential. PHI includes patient name, phone number, email, date of birth, date of death, date of admission/discharge, social security number, medical record number, account number, device/serial numbers. It further includes information concerning your past, present, and future condition and documentation (for a complete list, visit www.Greten.org). PHI information also includes financial and insurance information.

How we use Patient Health Information (PHI)The Greten Family Practice Privacy rights provided to each patient, details how your PHI is used. Your PHI is used/disclosed for treatment, payment, and operation purposes in accordance with federal HIPAA regulations. We may also share PHI for purposes permitted by law.

Treatment use/disclosure: PHI is used/disclosed to provide medical treatment and services. This may include: health care professional participating in your care,

pharmacists to fill prescriptions, labs/ outside affiliates performing medical tests, family member (you designate) to participate in your care (See advance directive packet provided with privacy practices).

Payment: PHI is used/disclosed to obtain preauthorization from your insurance for services. PHI is used/ disclosed to submit insurance claims and receive

reimbursement for services. PHI may be shared with billing companies, insurance companies, collections, and government agencies.

Operations: PHI is used/disclosed within this office to perform routine functions such as: quality improvement, resolving your compliant, staff training, and billing staff. PHI may

be shared with you or your designated health officiant to provide information about testing, labs, referrals, and follow-ups delivered by phone as consented.

Special situations in which we disclose PHI without consent: Greten Family Practice is required by law to release PHI in cases of abuse and crime wounds

(stabbings, gunshot wounds, assault). In the matter of public safety required by law we are required to release information of

infectious disease to the appropriate government agency. Greten Family will release PHI upon receipt of a court order. Workers compensation patients waive their right to PHI related to their workers comp case.

Page 1 of 2


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Patient Rights:You have the right to restrict and/or revoke PHI disclosure authorization at any time. The request to do

so must be submitted in writing to Greten Family Practices. Requests may take 30 days to process upon receipt. We will make every possible accommodation for restriction requests. Further, revoking authorization does not and will not include PHI released prior to the request.

You have the right to receive access, copies, and/or inspection of your medical records. There may be a cost for copies at the expense of the patient and are subject to change without notice. If you contest information contained or lacking in your records, you have the right to request in writing an amendment. Greten reserves the right to deny amendments that are not supported with sufficient proof.

You have the right to be informed when your PHI is illegally accessed (breached). Greten will inform you within 30 days after it has been brought to our attention. You have the right to complain or file grievance. Your contact information is: US Department of Health 646 Delder Lane, Walla, NY 13117.

You have a right to be informed of changes to our privacy policy, HIPAA law changes of uses/ disclosures, and other Greten policies pertaining to your medical records. We will post updates to our website (www.Greten.org) and on our bulletin in the office for a minimum of 30 days before changes are made.

I, _____________________(D.OB.) _________________ authorize Greten Family Practice and its’

medical professionals to use/disclose my patient health information for the purpose of treatment,

payment, and operations in accordance with HIPAA and legal regulations. This authorization goes into

effect ________________ and will expire on______________ in which a renewal authorization will be Today’s date One year (365 days) from today’s date

signed unless or until I revoke my authorization in writing. I understand my rights regarding PHI. I have

received and understand the copy of Greten Family Practice Privacy Policy.

_________________________ _____________ _______________________________ __________Patient name (print) Date of Birth Signature of Patient/guardian Today’s Date

______________________________________________________________________________________ ______________Greten Family Practice Staff Witness Today’s Date

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Policy and ProcedureSubject: Patient File Structure Policy # 1264Issue Date: July 20, 2017 Effective Date: August 1, 2017

Policy:It is the policy of Greten Family Practice, that all employees comply with and meet standards of patient file structure requirements. This policy establishes patient file structure standards in accordance with Greten Family Practice and New York State/ Federal record keeping standards.

Persons affected:This policy should be complied by all Greten Family Practice staff with special detail to the Medical Records Clerk position. Failure to comply with policy #1264, will be subject to and result in disciplinary action according to the disciplinary policy #1165.

Policy Text: (Stevens, 2016)It is the policy of Greten Family Practice to maintain the following order and retention criteria of patient files :Key:

Tab divider of file Included documents to be filed under the tab in chronological order and within their

own sub tab

Face Sheet (Permanently kept in floor chart) Includes demographic and patient information retrieved from Patient information form

Advanced Directives (Permanently kept in floor chart) Includes in order:

Patient consent formsDNRHealth Care ProxyLiving Will (if applicable)Organ donation information and consentPower of Attorney

History & Physical (Permanently kept in floor chart) Includes in order:

Medical records prior to becoming an established patient at our practiceFamily HistoryPast HistorySocial History

Progress Notes & Assessments (15 months kept in floor chart and then moved to back chart for a total of 10 years)

Includes: In-house encounters with the Nurse Practitioner and Physician


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Visits, annuals, and follow-ups in order of date of encounter

Orders (15 months kept in floor chart and then moved to back chart for a total of 10 years)

Consults (12 months kept in floor chart and then moved to back chart for a total of 10 years) Includes: out-side encounters such as specialists, referrals in order of date of encounter

Labs/ Testing (12 months kept in floor chart and then moved to back chart for a total of 10 years)

Includes: Results of testing and labs in order of date

Patient Communications (12 months kept in floor chart and then moved to back chart for a total of ten years)

Patient non-compliance Scheduled appoints including if apt was kept, missed with/without patient notice, and

rescheduling attempts Amendment requests and results (yes/no) and MR changes that were made (must also

apply in applicable chart section)

All Greten records will be stored for a set, specific time in the floor charts. Then they will be moved to MR office back charts for a total of 10 years.

Protocol #1264ARules of record order and retention according to Greten Family Policy align with NY state and federal regulations.

1. All patient records are to be kept, stored, and maintained in chronological order by all staff who encounter/ contribute to medical records (Booth, Whicker, & Wyman, 2017, 221).

2. All patient records are to be kept, stored, and maintained for 10 years.- Law requires 7 years retention for medical records and 10 years for financial record

retention (Booth, Whicker, & Wyman, 2017, 221). Due to the support MR have on finances, all records will be maintained for 10 years and NO less.

3. Floor chart compliance is the responsibility of ALL Greten staff including documentation currency and HIPAA.

4. Greten Family Practice medical records clerk will comply with time retention. It is the MR clerk responsibility to move floor charting to back charting. It is further the responsibility of the MR clerk to maintain all back charts in accordance with Greten Family policies, NY state, and federal standards.

Definitions:Back chart- medical record thinning used to keep the most currently used medical records accessible,

the excess medical documentation is stored in the same order in a chart maintained in the


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medical records office. The records are kept under lock and if access is necessary a request must be made with the medical records clerk.

Chronological Order- the order in which all chart sections are to be kept. The order is defined by the date and the most current information is always kept on top

Compliance- maintaining standards, rules, and regulations set forth by an authoritative figure. Expectations are found in written policy or under laws set by the state of NY or the federal government

Floor chart- the medical records for the patient that are most current or permanent access is required. They are kept in the reception area under lock – with access provided to all pertinent staff.

NY state/ federal standards- Legal obligations set forth by local and federal governments. Non -compliance may associate legal consequences.

Retention- the keeping, storing, and maintaining of patient records

Related (relevant) Policies/ Procedures:HIPAA policy: #1001 HIPAA procedure: #1001ADisciplinary policy # 1165

Contact:Have questions, concerns, or need clarity- seek your point of contact:Karen Stevens HR, Office manager125 Wash RoadSomewhere, NY 12457-5689(555) 2647 ext. 12227www.gretenfamilypractice.org

References:Booth, K.A., Whicker, L.G., Wyman, T.D. (2017). Administrative procedures for

medical assisting (6). McGraw-Hill; NY: NY.Stevens, K. (2016). Northwoods patient chart filing index. Retrieved from my

personal document creation file: created for MR position at Northwoods, NY.General reference for policy/ procedure writing:N.A. (2009, April). Nursing guide to practice office of professional NYSE pdf.

Retrieved from https://www.op.nysed.gov


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Policy and ProcedureSubject: Financial Reconciliation Policy # 2662Issue Date: August 22, 2017 Effective Date: Sept. 1, 2017

Policy:This policy establishes Greten Family Practice process of financial reconciliation in accordance with company policy and NY state standards.

Persons affected:Greten Family Practice accountant, billing staff including accounts receivable and accounts payable, and office managers are expected to comply with this policy and associated procedures/ protocol. Failure to comply will result in disciplinary action as dictated by the disciplinary policy #1165.

Policy Text:It is Greten Family Practice standard to complete the process of financial reconciliation upon receipt of each and every bank statement, usually on a monthly basis. It is further policy to complete the process for each account separately and then comparatively the day it is received, for the financial well-being of Greten Family Practice. Greten Family Practice staff will utilize the company reconciliation worksheet (Booth, Whicker, Wynman, 2017, 456), document # AA14 to ensure consistency and accuracy of the reconciliation process.Billing staff are expected to follow and comply with financial reconciliation protocol #2662A in accordance with Greten Family Practice policy and NY state standards. Financial ledger and recordings, including reconciliation worksheets with bank statements are to be maintained in accounting office for a minimum of 10 years in accordance with practice policy and law dictates.

Protocol/ Procedure #2662AAll Greten Family Practice billing staff will use the financial reconciliation worksheet, document # AA14 as assigned by the accountant and/or office manager; while completing the step by step process below.

1. Adjust the bank statement balance to correct balance (+ means add, - means subtract, +/- means whichever is applicable)

Includes in order+ deposits in transit- outstanding checks+/- bank errors

2. Adjust the company records to correct balance (+means add, - means subtract, +/- means whichever is applicable)

Includes in order- bank service fees-NSF check/fees- check printing charges


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+ earned interest+ notes receivably collected by bank+/- errors in company records

3. Compare results from steps 1&2 4. Make an entry in the company ledger and attach Greten Family Practice financial

reconciliation worksheet with bank statement (to be maintained for a minimum of 10 years)

Definitions:Company records- refers to Greten Family Practice financial record keepingFinancial Reconciliation- cross checking bank statements with company records for consistency and to

make sure all finances are accounted for, permanent records are placed in ledge (including worksheet) and maintained for 10 years minimum.

Financial reconciliation worksheet- company document #AA14, used specifically for the reconciliation process to ensure consistency in our record keeping

Related (relevant) Policies/ Procedures:Disciplinary policy # 1165Document # AA14, reconciliation worksheet


References:Averkamp, H. (2017). Bank reconciliation. Retrieved from

https://www.accountingcoach.com/bank-reconciliation/explanationBooth, K.A., Whicker, L.G., Wyman, T.D. (2017). Administrative procedures for

medical assisting (6). McGraw-Hill; NY: NY.General reference for policy/ procedure writing:N.A. (2009, April). Nursing guide to practice office of professional NYSE pdf.

Retrieved from https://www.op.nysed.gov


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https://www.op.nysed.gov/

The CMS1500 is a standard paper claim used by health care professional and suppliers to

bill medical contractors, some government, and some private insurance companies. Generally

(not always), they are used in an outpatient setting. This claim form is regulated and maintained

by the Centers for Medicare and Medicaid (CMS) (CMS.gov, 2017). Many of the boxes are

necessary to receive reparation; while, others are variably required depending on payer

requisites. Further differentiating factors may depend on the presence of secondary insurance.

This summary discusses the example CMS1500 form and concludes with the submission

process.

The provider in the example form is seeking reparation from a commercial, group

insurance for a patient seen on a mid-level spectrum E/M visit. The visit addressed a diagnosis:

osteoarthritis of the knee, unspecified with anesthesia (numbness). Which, was treated in the

office with a trigger point injection for pain management. The CMS1500 claim form is

completed to the commercial, group insurance standards and may not reflect all payer standards.

Box one (1&1a), identifies a group plan and includes the associated insurance number.

When completing this box, refrain from the use of hyphens. Box two through houses pertinent

patient and policy holder information (Green & Rowell, 2017, 447). In the example, the patient

and policy holder are the same. So, the information is repeated. Box eight, is not necessary for

this submission, but there will be no penalty for addressing it. Nine, is only completed when

secondary insurance exists. In the sample, this is not applicable. Field ten, recognizes the visit

did not pertain to work, a car accident, or accident (Green & Rowell, 2017, 447).

Further, box eleven is necessary to tell the payer what the group number (not applicable

to all situations). 11a and c are used to identify the insured and the plan of coverage. One

insurance company may support multiple plan options that offer different payments. To ensure

proper reparation, the plan should be noted. 11b however, is used only in a workers’


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compensation situation. The next two fields (12&13), are critical to the CMS1500. Signature on

file (SOF) may be accepted, but it is important to understand the bill is unpayable if left blank

(Green & Rowell, 2017, 448).

Field 14-18 ask for case specific information and addressed when applicable to the case,

as payer requires. 19 should be left blank. Moving forward, 20 is only used when lab services

have been rendered. Diagnosis (dx) codes are found in box 21. The code set used should be

identified (0 = icd10, 9 = icd9) and this information is essential. Payers use this field in

conjunction with 24 to determine medical necessity, which makes the claim payable. 24

expresses encounter information such as: place of service, CPT codes, dx pointers, and the

number of units (Green & Rowell, 2017, 449). In the example, 99213 supports M17.9 and the

modifier (25) is significant because it expresses a separate, significant procedure was conducted.

Which was 20552 to treat R20.0. Box 22 is left blank and 23 is used for preauthorization, when

necessary. The last few boxes are important to receive reparation. 25 recognizes the provider

EIN/SSN, 26 patient account information, and 27 accept assignment (Green & Rowell, 2017,

450). There are multiple insurances that require acceptance of assignment to pay. This means the

provider will accept the reparation as payment in full for service. Encounter/ account charges are

located 28-30. While, 31-33 are the last boxes; they are certainly essential (Green & Rowell,

2017, 450). Provider and facility data tell the payer where to send the payment.

Properly completing the CMS1500 is critical or the request can be denied or delayed,

elongating the reparation process. Multiple claims form a data packet when submitted

electronically (clearinghouse / software). They are received via payer modem. Initial edits are

conducted to determine if the packet batch complies with basic HIPAA requirements. If not, the

entire batch can be rejected for correction and resubmission. Passing, the packet is separated to

individual edits against HIPAA claim standards. Further, patient coverage is verified. As well as,

compliance with payer requirements. If the requisites are met, acknowledge will be reported

(CMS.gov, 2017). Manual submissions are not subject to the same HIPAA scrutiny and are

rarely used anymore (special circumstances). Either way, errors at any level of processing are


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grounds for delays and denials that pose detrimental consequences to a provider’s financial

stability.


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The encounter form is a beneficial tool that aids accurate charge application for the

billing of professional services. It also aids data collection for individual and analysis purposes.

Many encounter forms are built on practice common, specific encounters. For example, a family

practice may utilize annual check-ups or vaccine headers. Individual attributes will be explained

referencing the available sample encounter form. Although this form can be tailored to specialty,

some information should be included on all versions. When applied correctly, this form can

streamline a complex billing process. The encounter form should be updated annually with code

changes.

There are fields that should be incorporated on all encounter forms. First the headers

should include, the patient name, DOB, and associated medical record number are necessary to

identify service recipient and will transfer directly to the appropriate claim form. The date of the

encounter should be included because claims may be filed at a later date and it offers an easy

reference. Also, the place of service should be present (UHC, 2014). The body of the form

supports subheadings of services commonly conducted in a specific place of service. Each

subheading should be followed by a series of service descriptions (UHC, 2014). For example, a

subheading of E/M services would be followed by all possible levels of visits. Next to the

descriptions are the appropriate CPT codes. They may be further detailed by new/established

patient, as applicable. Each subheading should offer possible modifiers specific to that section

(UHC, 2014). In the example, modifier 25 is required to identify a separate, significant procedure

was conducted in addition to the E/M visit. A place to check the description that applies, helps to

identify the service and the correct CPT is circled. A good encounter form offers blank space for

written descriptions/details that add specifity to the encounter and/or special billing instructions.

These spaces will identify circumstances that make the bill unusual (UHC, 2014).

Other pertinent information is required for encounter forms. There should be a spot for a

current dx code and/or dx narrative. Lastly, the provider name, signature, and date should be

present to certify services provided.


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The sample encounter form associates with the CMS1500 case. It is tailored for a family

practice. The header supports patient information including: name, address, phone number,

account number, and DOB. It houses insurance data such as: plan name, policy holder, insurance

id, and group number. There is also a charge section that entails: date of service, copay, previous

balance, encounter charges/payment, and balance due. This information is easily transferred to

the claim form for submission. Reading the mid-section, the established patient had a mid-level

E/M visit with a significant, separate procedure; two injections. Diagnosis listed include R20.0

and M17.9 (ICD-10, 2017). Recording the encounter in real time aids proper claim completion. It

simplifies the process and ensures proper code application. As well as, accurate payment

requests. That being said, the provided information should be crossed referenced with medical

records as a means of claim assurance.

Encounter forms allow an otherwise complex process (billing/coding), to be streamlined

and improve accuracy. This tool can be tailored specifically to a practice. However, certain

information should exist on all encounter forms. This medical document includes patient PHI

and is protected under HIPAA standards. Capturing the encounter in real time attributes to

accurate data retrieval.


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The UB 04 is a standardized form used to bill providers for institutional services. The UB

04 is also known as the CMS 1450 and is maintained by the National Uniform Billing

Committee (NUBC) (Green & Rowell, 2017, 356). Generally, this form is used for inpatient

services and may be utilized by different institutions. For example, ambulatory surgical centers,

hospitals, skilled nursing facilities, and rehabilitation centers (psychiatric/ drug) use the UB 04

for billing. Other facilities that may use it may include (but not limited to) walk-in clinics,

hospice, labs, and home health agencies (Green & Rowell, 2017, 356). The CMS 1450 will have

fields necessary for all claim submissions. Payers and payer requisites will further detail

necessary completion requisites. To seek and receive reparation, the form must be completed to

the payer standards. This summary details claim information, while referencing the provided

sample.

The provider in this sample is requesting payment from Aetna (commercial payer) for a

patient seen at a rural clinic on an outpatient basis for a chest x-ray service. The chest x-ray is

supported by a COPD diagnosis. There are many fields on this form, some of which are self -

explanatory. Such as patient, insurance, and provided information discussed in the CMS1500

summary. I would like to address the fields unique to the UB04 form.

Field four describes the type of bill presented. It is represented by four digits. Each digit

represents a specific description. First, zero is always the leading number. The second digit refers

to the type of facility. In the example 1 is used to identify a hospital. The third digit is the bill

classification. The sample identifies 3 for an outpatient encounter. The fourth digit can be alpha

or numeric and tells the frequency. The example uses 1 to show admit through discharge claim

(Green & Rowell, 2017, 357-58).

Fields 13- 17 are also identified using coded alpha numeric digits. For example, 14 is

used for inpatient claims to identify the type of admission. The sample is an outpatient, so this

field is not required. Box 15, is the source of the referral and is required. For instance, 1 depicts a

physician referral is what prompted the service. 17 is also required that defines the patient

discharge status (Green & Rowell, 2017, 360). In this case, 01 means the patient was released to

their own care. This should be a two-digit response. Moving forward, 18-28 are conditionally


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used to support adjusted and reopened claim. Occurrence codes used 31-34 are situational and

can identify special circumstances, such as accidents (Green & Rowell, 2017, 362).

Unlike occurrence codes, value codes are required for submission of any type of bill.

They are two-digit codes related to service and a monetary value necessary for processes a claim.

In the example, B2 is used to identify an outpatient coinsurance of $15.00. Revenue codes are

also not optional (Green & Rowell, 2017, 363). They are in field 42 and describe the service

provided to the patient. Generally, four digits the example uses 0324 and is defined in the next

field as a chest x-ray with a single view. Field 44 is also important for claim submission. 71010

is a procedure code entry. Like the CMS 1500, procedure and dx codes prove medical necessity.

The diagnosis code is found in field 66, J44.9. Also similar, the requirement of NPI numbers that

are verified through the tax EIN/ SSN.

As you can see, there are similarities in the information provided between a CMS 1500

and a CMS 1450. Both, must address required and payer necessary information to accepted and

paid. The differences are found in the structure of the information and the format of presentation.

The UB04 form uses a lot of coded information and is set to a high HIPAA standard. It is unique

and valuable to maintain regulatory standards.


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ReferencesGreen, M.A., Rowell, J.C. (2017). Understanding health insurance: a guide to billing and

reimbursement (13). Cengage; Boston: MA

N.A. (2016). Billing: electronic billing. Retrieved from

https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITTrans/16_1500.html

N.A. (2014). Uniformity: encounter forms. Retrieved from https://www.ooc.usc.edu/policy-to-b-

04/uniformity-encounter-forms


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Medicare Insurance Tip SheetThe provided information is not all information necessary for clean claim submission and should not be the sole resource for dealing with the payer. Rather, it is a quick reference to guide contact, eligibility verification, claim form selection, and deadline information. It may include (but not all inclusive) billing types for the carrier. Further, information content is state specific to New York divisions.

Contact information: (Medicare.gov)

General information (billing, claims, or expenses)

1-800-633-4227

Talk to a person 1-877-486-2048Address Centers for Medicare and Medicaid

7500 Security Blvd.Baltimore, MD 21244-1850

Eligibility Verification: (Medicare.gov)To confirm patient eligibility call: 1-800-633-4227

Claim Form: (Green & Rowell, 2017, 495)CMS-1500 standard claim form for our practice. Medicare A- UB04 form

Medicare B-CMS1500 form

Medicare C- UB04 or CMS1500 form (depends on service)

Submission: (Green & Rowell, 2017, 523-24)* Submitted electronically using optical scanner guidelines. The provider is REQUIRED to file claims for patients with this insurance.

*DME claims must be sent to 1/4 regional contact for processing

* Submit two claims for one encounter if:- multiple referring, ordering, supervising, and provider identifier # required for block 17 and 17a-when multiple facilities are required for block 32-when DME is charged to patient at same time paitent had a reimbursable encounter-when a paitent has received covered lab services and other medical/ surgical during a nonPAR provider visit

Deadline: (Medicare.gov)Deadline for claim submission is one calendar year from the date of service.An unpaid claim must allow 45 days to pass before resubmission.


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Billing Tips: (Green & Rowell, 2017, 524-527)Caution- This payer requires many details on claim form not required by other payers. For example, the provider MUST accept assignment.

Boxes to double check for applicability (* are required, unstarred are case specific)*1, a *2 *3 4 *5 7 9,a,d *10

a-c*11 *12

13 *14 16 17, b 18 20 *21 23 *24, a,b,d,e,f,g,j

*25

*26 *27 *28 29 *31 *32, a *33, a

References:Green, M.A, Rowell, J.C. (2017). Understanding health insurance: a guide to billing and

reimbursement (13). Cengage: Boston; MA

N.A. (2017). Medicare billing guide. Retrieved from https://www.Medicare.gov


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https://www.Medicare.gov/

Medicaid Insurance Tip SheetThe provided information is not all information necessary for clean claim submission and should not be the sole resource for dealing with the payer. Rather, it is a quick reference to guide contact, eligibility /types for the carrier. Further, information content is state specific to New York divisions.

Contact:(Medicaid contacts, 2014)Long term care insurance 1-888-697-7582Complaint line NYS DOH 1-800-206-8125Medicaid Help Line DOH 1-800-541-2831Child Health Plus 1-877-898-5849Family Health Plus 1-877-934-7587Prompt payment for providers NYS 1-800-342-9871Billing guidelines 1-800-343-9000Address Centers for Medicare and Medicaid

7500 Security Blvd.Baltimore, MD 21244-1850

Eligibility Verification: (emedny.com)The MEVS (Medicaid eligibility verification service) process must be completed for each patient, each visit. Access MEVS terminal CPU code 2417 OR call 1-800-997-1111 OR 1-800-343-9000. You can verify up to three transactions in one call.

Claim Form: (emedny.com)837P electronic, CMS1500 form

Submission:(emedny.com)Submit electronically using optical scanner guidelines.

*ALWAYS LAST PAYER TO BE BILLED

Deadlines: (Well care, 2016, 82, 91)In- network claims 120 days from date of service.As a second payer, 90 days from date of service.Out of network claims 15 months from date of service.

Billing Tips:(Green & Rowell, 2017, 559-561)Provider MUST accept assignment.

Boxes to double check for applicability (* are required, unstarred are case specific)*1, a *2 *3 *5 9, a, d *10 a-

c10d 17, b 18 20

*21 22 23 *24a, b, d,e,f,g,h,

24c *25 *36 *27 *28 *31


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j*32, a *33, a

References:

Green, M.A., Rowell, J.C. (2017). Understanding health insurance: a guide to billing and reimbursement (13). Cengage: Boston; MA

N.A. (2014). Medicaid Contacts. Retrieved from https://www.health.NYS.gov

N.A. (2017). NYS Medicaid general professional billing guide. Retrieved from https://www.emedny.org./provider-manual

Well care (2016). Medicaid provider manual- NY. Retrieved from https://www.medicaid.NYS.gov


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BlueCross BlueShield Insurance Tip SheetThe provided information is not all information necessary for clean claim submission and should not be the sole resource for dealing with the payer. Rather, it is a quick reference to guide contact, eligibility /types for the carrier. Further, information content is state specific to New York divisions.

Contact: (BCBS Excellus.com, 2017)BCBS Waterloo, NY 1-315-220-0717Excellus BCBS Syracuse, NY 1-315-671-6400Excellus BCBS Elmira, NY 1-800-499-1275Provider Portalhttps://www.excellus.BCBS.com/wps/portal/X1/provider/coding-billing

Fee schedules, claim filing, payment/remittance advice, submitting MR, check claims, referrals/ authorizations, view policies, staff training, print forms, clinical practice guidelines for individual services.

Eligibility Verification:(BCBS Excellus.com, 2017)The easiest way to verify eligibility is through the provider portal.

https://www.excellus.BCBS.com/wps/portal/X1/provider/coding-billing

Claim Form: (Green &Rowell, 2017, 474)CMS1500

Submission: (Green &Rowell, 2017, 474)Submit claims to local BCBS, electronically using optical scanner guidelines.

* Submitting as a secondary payer we must attach primary remittance advice.

Deadlines: (Green &Rowell, 2017, 474-75)One year from the date of service, unless otherwise stated in the contract (some specify 120 days

to 18 months).An unpaid claim must allow 30 days to pass before resubmitting.

Billing Tips: (Green &Rowell, 2017, 476-479)All providers qualify for assignment of benefits.Boxes to double check for applicability (* are required, unstarred are case specific)

*1, a *2 *3 *4 *5 *6 *7 9, a,d *10 a-c

11

11a, c, d

*12 *14 17, b 18 20 *21 22,23 *24a, b, d, e, f, g, j

*25

*26 *27 *28 *31 *32, a *33, a


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References:

Green, M.A., Rowell, J.C. (2017). Understanding health insurance: a guide to billing and reimbursement (13). Cengage: Boston; MA.

N.A. (2017). NYS Excellus BCBS. Retrieved from https://www.bcbs.Excellus .com


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Aetna Insurance Tip SheetThe provided information is not all information necessary for clean claim submission and should not be the sole resource for dealing with the payer. Rather, it is a quick reference to guide contact, eligibility /types for the carrier. Further, information content is state specific to New York divisions.

Contacts: (Aetna.com, 2017)Aetna 1-855-456-9126Complaints Aetna

55 West 125th St. Suite 1300New York, NY 10027

Provider Portal Eligibility, find PAR, check claim status, check for remittance advice, check authorization status

Eligibility Verification: (Aetna.com, 2017)To verify eligibility, call 1-855-456-9126 option 3 (M-F 8-5 ET).Go to the provider portal 24/7.

Claim Form: (Aetna.com, 2017)This office will use CMS1500. CMS1500 or UB04, depending on service provided.

Submission: (Aetna.com, 2017)Claims are submitted electronically using optical scanning guidelines via EMDEON id# 34734.

*Previously denied claims MUST be submitted via paper submission to:Aetna Better Health (NY)P.O.Box 63848Phoenix, AZ 85082

Deadlines:(Aetna.com, 2017)Claims must be submitted 120 days from date of service.Resubmission claims must be submitted 180 days from date of service.

Billing Tips:(Green & Rowell, 2017, 449-451)

Boxes to double check for applicability (* are required, unstarred are case specific)*1, a *2 *3 *4 *5 *6 *7 9, a, d *10

a-c11

*11a, c, d

*12 *13 *14 15 16 17, b 18 20 *21

22 23 *24a, b, d, e,

*25 *26 *27 *28 *29 *31 *32, a


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f, g, j*33, a

References:

Green, M.A., Rowell, J.C. (2017). Understanding health insurance: a guide to billing and reimbursement (13). Cengage: Boston; MA

N.A. (2017). Provider billing guide manual. Retrieved from https://www.Aetna.com


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Policy and Procedure

Subject: Internal HIPAA Compliance Audit Policy # 8870Issue Date: 05/27/2017 Effective Date: 6/01/2017

Policy: It is the policy of all Greten Family Practice staff to comply with HIPAA regulations including the Security rule, Privacy rule, and regulations in the event of a Breach. To ensure compliance with state and federal regulations, it is the policy of Greten Family Practice to conduct bi-annual audits as required by provisions risk assessment and risk management. This policy establishes guidelines and a checklist to conduct HIPAA audits under OCR standards.

Persons affected:All Greten Family practice staff must comply with HIPAA standards. Any staff member that has regular contact and/or access to PHI is mandated to comply with these standards. Failure to comply could result in fines, criminal, and/or civil action. Failure to comply will also result in disciplinary action that comply with Greten policy #1165.

Policy Text:It is the policy of Greten Family Practice to conduct bi-annual audits to ensure the practice is HIPAA compliant in accordance with regulatory standards. It is further required to conduct risk assessments and risk management to maintain compliance to which this audit will achieve. Items set forth by the OCR (office of civil rights) will be categorized by the risk assessment and risk management (security rule and privacy rule).

Risk assessment checklist: PHI Greten creates, receives, stores, and transmits Identify human, natural, or environmental threats Assess protection measures (Internal HIPAA risk management audit) Detect potential impacts of possible breaches Document findings and implement corrective measures including adding to the

audit processRisk management/ Internal HIPAA Audit checklist will include:

Security Rule (technical safeguards) (Internal Audits, 2017) EPHI is encrypted Mechanisms are in place and effective to authenticate EPHI Staff (allowed access) have a user ID, PIN, encryption/decryption

functions, and are provided procedures to govern the release of EPHI in the event of an emergency

Audit activity controls are effective and in place Automatic log off controls are effective and in place

Security Rule (Physical safeguards) (Internal Audits, 2017)


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There is a current list of personnel who have access where PHI is stored Workstations are restrictive to viewing of PHI There are policies and procedures in place

Security Rule (Administrative safeguards) (Internal Audits, 2017) Risk assessment are conducted and documented Risk management includes policies of sanctions against non-compliant

staff Employee training occurs at minimum annual and there is documentation There is a contingency plan in place to protect EPHI/ PHI in the event of

an emergency plan Third party access is restricted through contractual agreements

Privacy Rule (Hurt, 2017) Privacy Policies are current Employee training conducted and documented annually Patient written permission has been documented and filed (current) Integrity of PHI is maintained at all times- conduct random floor walk

throughs confirm not PHI is visible on desks or computer screens, computer and workstations are locked with no access to passwords (sticky-notes), and discarded PHI is shredded (not thrown in the trash or stacked in a box)

Protocol #8870ARules of Internal HIPAA audits are in accordance with state and federal standards to maintain safeguards to protect PHI. Internal audits are to be conducted biannually and will ensure readiness for an OCR audit.

1. Audits will be conducted only be administrative staff who already have access and authority over PHI and policies.

2. Audits will be conducted bi-annually using the check list (above) that addresses all regulatory standards.

3. Internal HIPAA audit checklists are to up-dated with annual policy revisions and/or in accordance with regulatory changes.

4. Audits are to be maintained and stored with risk assessment and management as documentation of mandatory compliance.

Definitions:Breach- unauthorized attainment of medical records, personal health informationEPHI/ PHI- personal identifiable health information, electronic or otherwiseHIPAA- Health Insurance Portability and Accountability Act; US law to protect patient privacy

and sets standards for records created, received, stored, and transmitted


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OCR- Office of Civil RightsSanctions- penalties for disobeying law

Related Policies/ Procedures:

HIPAA policy: #1001 HIPAA procedure: #1001A Disciplinary policy # 1165 Protocol #8870A


References:Hurt, A. (2017). How to conduct a HIPAA audit. Retrieved from

http://www.physicianspractice.com/how-to-conduct-a-hipaa-audit

N.A. (2017). Internal audit: hipaa. Retrieved from https://www.hhs.gov/ocr/


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Policy and Procedure

Subject: Patient Medical Records Audit (includes: patient information check)Policy # 8879Issue Date: 05/27/2017 Effective Date: 6/01/2017

Policy: It is the policy of Greten Family Practice to maintain detailed, efficient patient medical records to provide optimal patient care and receive appropriate reparation of services. It is further policy of Greten Family practice to comply with state, federal, and in-house regulations regarding storing, maintaining, and use of patient medical records. This policy establishes guidelines for Greten Family Practice monthly chart audits.

Persons affected:This policy should be complied by all Greten Family Practice staff with special detail to the Medical Records manager position. Failure to comply with policy #8879, will be subject to and result in disciplinary action according to the disciplinary policy #1165.

Policy Text:(omic.com, 2017)It is the policy of Greten Family Practice to conduct monthly medical record audits to ensure quality, organization, compliance with Greten policies, and compliance with state and federal record keeping standards. Each month 10 active patient records will be selected for review. Pulled charts will follow a progressive checklist. The checklist will be Greten worksheet #64 A to be used by the Medical Record staff. The worksheet is to be utilized each time for consistency and quality auditing.

Items included in the evaluation checklist will be: (omic.com, 2017) Chart sections are in order according to Greten Family Practice policy #1264 Chart documents in each section are in chronological order Documents are fastened securely in the chart Entries are legible, dated, and contain patient ID number Medical staff providing care are identified in each entry Patient information on face sheet is as complete and up to date as possible No inappropriate changes or omissions exist Issues stated by the patient have been addressed in each encounter Counseling and patient education is provided and proved in the documentation Telephone interactions are documented regarding the patient (includes

missed/cancelled appointments and f/u visits scheduled) Immunization records are present and current Prescriptions including a medication list are maintained and accurate Proper H&P are conducted and documented accordingly Procedures and treatments are justified by the diagnosis


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Consult summaries include evidence of the coordination of care among primary and referred specialists

Protocol #8879ARules of Medical Record audits according to Greten Family Policy align with NY state and federal regulations.

1. Each month 10 active patient records will be selected (not to repeat same chart within 1- year time) for review. Pulled charts will follow a progressive checklist. The checklist will be Greten worksheet #64 A to be used by the Medical Record staff. The worksheet is to be utilized each time for consistency and quality auditing (omic.com, 2017).

2. For each chart a rating of 3, 2, 1 will be given. 3 means the item on the list has been addressed adequately. 2 means there is need for improvement and 1 means the item is unacceptably recorded/ kept.

3. All audit slips are to be maintained in a locked record in the Medical Records office and only pulled for audit purposes. As a precaution, these documents may contain PHI and therefore will be treated and subject to HIPAA standards.

4. The Medical Record manager will complete the monthly Medical Record audit or may dictate at his/her discretion, a responsible party.

5. Results of the audit are to be analyzed by the Medical Records and Office manager who will decide if further staff training, disciplinary actions, or other measures are necessary to ensure compliance with set standards.

Definitions:Chart- chart, medical records, patient records are interchangeable termsf/u- a follow up appointmentH&P- history and physicalOmissions- pertinent information left out

Related Policies/ Procedures:HIPAA policy: #1001 HIPAA procedure: #1001A worksheet #64 ADisciplinary policy # 1165 Protocol #8879A

Contact:Have questions, concerns, or need clarity- seek your point of contact:Karen Stevens HR, Office manager125 Wash Road


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Somewhere, NY 12457-5689(555) 2647 ext. 12227www.gretenfamilypractice.org

Record #Rated 3- acceptable 2- need for improvement

1- unacceptable

ItemPresent

1 2 3 4 5 6 7 8 9 10

Chart Sections are in order according to Greten Family Practice policy #1264Chart documents in each section are in chronological orderDocuments are fastened securely in the chartEntries are legible, dated, and contain patient ID numberMedical staff providing care are identified in each entryPatient information on face sheet is complete and currentNo inappropriate changes or omissions existIssues stated by the patient have been addressed in each encounterCounseling and patient education is provided and proved in documentationTelephone interactions are documented regarding the patient including missed/canceled appointments & f/u scheduleImmunization records are present and currentPrescriptions including a medication list are maintained and accurateProper H&P are conducted and documented accordinglyProcedures and treatments are justified by the diagnosisConsult summaries include evidence of coordinated care between primary and referred specialists

Greten Family Practice Medical Record Audit Checklist/ Worksheet (omic.com, 2017) Page 3 of 3

References:

N.A. (2017). Medical record chart audit. Retrieved from https://www.omic.com/medical-record-audit-form


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Somewhere, NY 12457-5689(555) 2647


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