Insurance Claims and the CMS FormInsurance Claims and the CMS Form

Types of ClaimsTypes of ClaimsPaper Claim; submitted on paper via fax or Paper Claim; submitted on paper via fax or regular mailregular mailElectronic Claim; send via modem through Electronic Claim; send via modem through clearing houseclearing houseDigital Fax; send via fax through computer-Digital Fax; send via fax through computer-never on papernever on paper

Problem ClaimsProblem ClaimsDingy Claim; held by Medicare when claim Dingy Claim; held by Medicare when claim cannot be processed for service or bill typecannot be processed for service or bill typeDirty Claim; has errors or needs problems Dirty Claim; has errors or needs problems resolved. May be classified as “pending”.resolved. May be classified as “pending”.Rejected Claim; due to above and/or requires Rejected Claim; due to above and/or requires investigation for further clarification. Should investigation for further clarification. Should always be resubmittedalways be resubmitted

Incomplete claim; missing informationIncomplete claim; missing information Invalid claim; illogical or incorrect (wrong Invalid claim; illogical or incorrect (wrong

provider numbers, etc) provider numbers, etc)

Note: Clean Claims contain all necessary Note: Clean Claims contain all necessary information and can be processed and information and can be processed and paid promptly. paid promptly.

Places of service:Places of service:

11 office11 office 12 home12 home 21 Inpatient Hospitalization21 Inpatient Hospitalization 22 Outpatient Hospitalization22 Outpatient Hospitalization 23 ER-Hospital23 ER-Hospital 24 Ambulatory Surgical Center24 Ambulatory Surgical Center

EOB’s (Explanation of Benefits)EOB’s (Explanation of Benefits)

Tell:Tell:Patient’s name and policy numberPatient’s name and policy numberProvider of servicesProvider of servicesDates of servicesDates of servicesDate claim receivedDate claim receivedServices or proceduresServices or proceduresAmount billed by MDAmount billed by MDAmount allowed/disallowed by insurance carrierAmount allowed/disallowed by insurance carrierLess deductible amountLess deductible amountCo-payment/coinsurance due from patientCo-payment/coinsurance due from patientTotals paid by insurance carrierTotals paid by insurance carrierComments Comments

Claim ManagementClaim Management Insurance claims register-pending file if submitting via Insurance claims register-pending file if submitting via

paperpaper Insurance payment history-if submitting via paperInsurance payment history-if submitting via paper

Types of Common ProblemsTypes of Common Problems Delinquencies-Payments overdueDelinquencies-Payments overdue Pending/suspense claims-still in reviewPending/suspense claims-still in review Lost claimsLost claims RejectedRejected

Transposed numbersTransposed numbers Missing, invalid or incorrect codes/modifiersMissing, invalid or incorrect codes/modifiers Missing provider, provider ID#, referring providerMissing provider, provider ID#, referring provider Incorrect dates of serviceIncorrect dates of service Code descriptors that do not match Code descriptors that do not match Duplicate dates or chargesDuplicate dates or charges

Denied due to medical coverage policy issues or program Denied due to medical coverage policy issues or program issuesissues

DowncodingDowncodingHappens when insufficient diagnostic information Happens when insufficient diagnostic information

is on claim and/or when coding for lesser is on claim and/or when coding for lesser services than were performedservices than were performed

UpcodingUpcodingHappens when coding higher for services than Happens when coding higher for services than

what was performedwhat was performed Partial paymentPartial payment

ResubmitResubmit Payment made to patient-collectPayment made to patient-collect Over payment-deposit and send refund to Over payment-deposit and send refund to

insurance companyinsurance company Rebilling-q 30 daysRebilling-q 30 days

Claim InquiriesClaim InquiriesSubmit tracers for:Submit tracers for: payments not received in timely payments not received in timely

mannermanner investigation under wayinvestigation under way amount received wrongamount received wrong patient’s responsibility not clearly definedpatient’s responsibility not clearly defined wrong patient/right officewrong patient/right office code different than was submittedcode different than was submitted service stated as disallowedservice stated as disallowed error on EOBerror on EOB check made out to wrong MD check made out to wrong MD

Appeals-send letters, call insurance Appeals-send letters, call insurance companycompany