Claim Submissions PDF

How will we be submitting our claims? In order to submit a claim, we’ll need to have collected the patient's demographic data and their insurance details. We’ll get their demographic data from their intake paperwork and we'll copy or scan the front and back of their insurance card(s) so we have acce...

How will we be submitting our claims? In order to submit a claim, we’ll need to have collected the patient's demographic data and their insurance details. We’ll get their demographic data from their intake paperwork and we'll copy or scan the front and back of their insurance card(s) so we have access to their insurance policy and contact information. I also recommend scanning or copying their ID or their legal guardian's ID. We can submit our claims to the insurers through a number of different avenues: Directly: Insurers often have an online provider portal for submitting claims directly. This is usually the fastest and most efficient way to submit claims as you have the eligibility information accessible just before you begin submitting the claim. For example, multiple insurers utilize Availity.com for their direct submission. Availity is a third-party portal for numerous insurers. Availity Portal Registration Indirectly through a clearinghouse: Not every insurer has a direct provider portal or perhaps they have one that is cumbersome and confusing. As an alternative, we can submit our claims through a third party called a claims clearinghouse. A clearinghouse is a go-between for our office and insurance companies. Clearinghouses have a few nice benefits for insurance claim filing: they will check the claim for coding errors (“claim scrubbing”), hold the prepared claims until they can be sent as a batch, electronically exchange information with the insurer and provide remit information, and allow a method to fix claim rejections or denials. At my office, we submit some insurance claims through Availity and some through our clearinghouse. Manually: Generally we're only submitting claims manually when the insurer doesn't have a direct provider portal, doesn't utilize Availity, and isn't registered with a clearinghouse. In those cases, we fill out a claim form and submit it via fax or mail it to the insurance claims address like we're pioneer people. The most common claim form utilized by insurances that don't provide a specific custom claim form is the CMS-1500 form. Understand your plan contracts. Make every effort to maintain strict compliance with the insurance plans' rules. The United States Department of Health and Human Services Office of the Inspector General (OIG) is the entity tasked with monitoring doctors for fraud, waste, and abuse with Medicare. The individual commercial plans manage fraud and abuse by data mining, predictive modeling, and monitoring billing pattern deviations. For example, if 90% of your exams are billed at a level 5 E&M code when your professional peers bill that code 4% of the time, you will attract the attention of the insurer. Try not to attract the attention of the insurer.