insurance claims processing chapter 15

Appeals generally must be in writing and initiated within ___________ days.

30 to 60

To complete the entire claims process, a paper claim normally takes

4 to 6 weeks.

How frequently claims are submitted can vary depending on

All of the above.

When it becomes necessary to include attachments with a paper claim, what provider information should appear on each document?

Attachments should include the practice name, provider/group number, address, and telephone number.

What are the basic rules for appealing a claim?

Basic rules for appealing a claim are (1) the appeal should be in writing; (2) always include a copy of the original claim, EOB, or RA; and (3) include any additional documentation necessary to provide evidence for the appeal.

What is the first key to successful claims processing?

Collecting and verifying patient information

List at least four ways for optimizing the billing and claims process.

Create a consistent scheduling planVerify insurance coverageCollect fees at time of serviceUtilize available technologyGenerate clean claims 0List at least four ways for optimizing the billing and claims process.

While coordination of benefits (COB) does not occur as often as it once did, it is still an occasional occurrence. What two things should a health insurance professional do when this situation arises?

Determine which payer is primary and which is secondary Send a copy of the EOB from the primary payer along with the claim to the secondary carrier; if the EOB is not included, the claim will probably be denied or delayed, pending COB determination

The key to knowing how much of the claim was paid, how much was not, and why is the

EOB

A nine-digit number required by businesses to serve as their taxpayer identifying number is the

Employer Identification Number (EIN).

A suspension file is a series of files set up alphabetically and labeled according to the number of days since the claim was submitted.

False

If a patient is incapacitated in any way, the health insurance professional is not allowed (by law) to contact the patient's insurer to obtain preauthorization.

False

Insurance companies usually have no time limits for filing appeals.

False

It is the patient's responsibility to document nonmedical comments in his or her own health record.

False

Medicare secondary payer claims are claims that are submitted to another insurance company after they are submitted to Medicare.

False

Only the provider has the right to appeal a rejected claim.

False

Participating providers can balance bill, but nonparticipating providers for commercial claims are not allowed to.

False

The book outlines 12 keys to successful claims processing.

False

The Medicare program has a multileveled appeal process. How many levels are there?

Five

Why should the health insurance professional photocopy both sides of a patient's health insurance identification card?

Frequently, the back of the insurance ID card contains pertinent information such as the address where to send the claim, telephone numbers for acquiring precertification, and/or customer service assistance for claims questions.

Explain how the Health Care Claim Status Inquiry/Response system works.

The provider uses the Health Care Claim Status Request (276 transaction) to request claim status information. The payer then responds to the request through the Health Care Claim Status Response (277 transaction) using the claim status category codes. Claim Status Category codes indicate the general category of the status (accepted, rejected, additional information requested, etc.), which is then further detailed in the Claim Status Codes.

After the patient information form is completed, the health insurance professional should check it over to ensure the information is complete and legible.

True

An explanation of benefits (EOB) is sometimes called a remittance advice (RA).

True

Before appealing a claim, the health insurance professional should notify the insurer in writing that there has been an error.

True

Correct code initiative edits are the result of the National Correct Coding Initiative.

True

HIPAA has developed a transaction that allows payers to request additional information to support claims.

True

Ideally, patients should be asked to update their information forms at least annually.

True

If a patient and his or her spouse are covered under two separate employer group policies, it results in a coordination of benefits.

True

Real Time Claims Adjudication (RTCA) allows instant adjudication of an insurance claim.

True

The EIN is a nine-digit number that serves as a taxpayer's identifying number.

True

The National Correct Coding Initiative (NCCI) develops correct coding methods for CMS that are intended to reduce overpayments that result from improper coding.

True

The claims process actually starts with the patient's appointment.

True

The type of Medicare coverage dictates the specific appeal filing process.

True

There are five different levels of the Medicare appeals process.

True

Verifying a patient's healthcare coverage is an important duty of a health insurance professional.

True

When a claims error that could result in inaccurate reimbursement is discovered, a corrected claim should be prepared and submitted according to the payer's guidelines.

True

When a patient signs an assignment of benefits, he or she is authorizing the insurance carrier to send payment directly to the healthcare provider.

True

If a health insurance professional discovers an error in a claim that could result, or already has resulted, in inaccurate reimbursement, what should be done?

Unless the health insurance professional is familiar with the payer's guidelines for such a problem, the payer should be contacted for instructions. Usually, a corrected claim should be prepared and submitted, and the health insurance professional should mark the corrected claim as a "corrected billing" and "not a duplicate claim." It is also advisable to include a note describing the error, plus any additional documentation necessary to support the correction.

List the six keys to successful claims processing.

Verifying patient informationObtaining necessary preauthorization/precertificationAccurate and complete documentationFollowing payer guidelinesProofreading the claim to avoid errorsSubmitting a clean claim 0List the six keys to successful claims processing.

Established patients should be required to update their information form

at least annually.

When initiating an appeal, in order that the appropriate steps are followed, the health insurance professional should consult the

carrier's guidelines

A suspension file is a series of files customarily set up

chronologically

Documenting the appropriate medical information in the patient's health record is the responsibility of the

healthcare provider.

Services that usually require preauthorization or precertification include

inpatient hospitalization.

An alternative to the suspension file is to record claims information on a columnar form called a/an

insurance claims register.

Providers cannot waive Medicare copayments unless ____________ has been established and documented.

legitimate financial hardship

Generally, if a claim is reduced or rejected, the problem lies with the

provider's office.

An explanation of benefits is often referred to as a/an

remittance advice.

If patients are covered by two insurance plans, the health insurance professional may have to submit a primary claim and a _____ claim.

secondary

Before the health insurance professional completes and submits health insurance claims, a __________ is typically on file.

signed and dated release of information