UNIT 4 CHAPTER 15 THE CLAIM Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.

2 SIX KEYS TO SUCCESSFUL CLAIMS  The First Key:  Collecting and verifying patient information  The Second Key:  Obtaining the necessary preauthorization precertification  The Third Key: Documentation

3 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.  The Fourth Key: Following payer guidelines  The Fifth Key:  Proofreading the claim to avoid errors  The Sixth Key: Submitting a clean claim

4 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. HIPAA’s Requirement for Employer Identification  Who requires employer identification numbers (EINs)?  Health plans  Clearinghouses  Providers  Employers

5 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. The Claim Process  Step One: The claim received  Step Two: Claims adjudication  Step Three: Tracking claims  Using a suspension file  Using the insurance claims register system  Step Four: Receiving payment  Step Five: Interpreting EOBs  Step Six: Posting payments

6 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Processing Secondary Claims  dual coverage (coordination of benefits [COB])  primary payer receives the first claim.  secondary payer gets EOB from the primary carrier  crossover claims

7 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Coordination of Benefits  When patient and spouse (or parent) are covered under two separate policies.  When a COB situation exists, the health insurance professional should:  Verify which payer is primary.  Send a copy of the EOB from the primary payer along with the claim to the secondary carrier.

8 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. The Birthday Rule The payer whose subscriber has the earlier birthday in the calendar year will generally be primary.

9 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Medicare Secondary Payer (MSP)  When Medicare beneficiaries have other insurance coverage primary to Medicare, a claim must be submitted to that insurer before it is submitted to Medicare.  The other insurer's payment information (EOB) must be included on the claim that is submitted to Medicare.

10 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Appeals  Both providers of service and patients have the right to appeal a rejected insurance claim or a payment made that the provider and/or patient feels is incorrect.  Payers usually have a set time limit for claim appeals and often print that information on their EOBs.

11 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Rules for Appeals  Appeals should be in writing (unless otherwise specified).  They must be submitted within the carrier’s time limit.  They should identify the claim and reason the provider feels the claim should be approved.  They should be sent directly to the carrier.  They must include any written comments, documents, records, or other information relating to the claim.

12 Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc. Five Levels of Medicare Appeals Process Level I: Redetermination by a Medicare Carrier, FI, or MAC Level II: Reconsideration by a Qualified Independent Contractor (QIC) Level III: Hearing by Administrative Law Judge (ALJ) Level IV: Review by Medicare Appeals Council Level V: Judicial Review in Federal District Court