MOA115_WK5_Assn_03182024
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Apr 3, 2024
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MOA115 Medical Records and Insurance Week
5 Assignment – Reimbursement Concepts Chapter 15 Medical Billing and Reimbursement Essentials A. Types of Information Found in the Patient’s Billing Record 1.
The patient’s billing record information is often found on the patient registration form.
Using Figure 15.1 in the textbook, list the billing information found on the patient
registration form. THE PATIENT LEDGER WITH THE RECORD OF CHARGES, ADJUSTMENTS, PAYMENTS, AND CURRENT BALANCE
B. Managed Care Policies and Procedures 1.
What items should the medical assistant gather when using the paper method to obtain a precertification for a service or procedure? THE PATIENT’S HEALTH RECORD, PRECERT REQUEST FORM, AND A COPY OF THE INSURANCE CARD
2.
Describe the processes for precertification using the paper method. What does the medical assistant need to do? CALL THE PROVIDER SERVICES PHONE NUMBER ON THE BACK OF THE INSURANCE
CARD, PROVIDE THE INSURANCE WITH PROCEDURES, DOCUMENT THE OUTCOME
3.
Describe the managed care requirements for a patient referral. OBTAIN A REFERALL AND/OR AUTHORIZATION PRIOR TO SEEKING SPECIALIST SERVICES
C. Submitting Claims to Third-Party Payers 1.
In your own words, identify the steps for filing a third-party claim. YOU HAVE TO HAVE A COPY OF THE PATIENTS INSURANCE CARD AND MAKE SURE THERES A RELEASE OF INFORMATION FORM SIGNED BY THE PATIENT ON FILE CORRECTLY COMPLETE ALL BOXES USING PATIENT AND INSURANCE INFORMATION AS WELL AS THE PHYSICIAN/SUPPLIER INFORMATION. ONCE EVERYTHING IS COMPLETE YOU CAN FORWARD THE CLAIM TO THE CLEARINGHOUSE
D. Generating Electronic Claims 1.
Describe the electronic claim form.
CMS-1500 SUBMITTED DIRECTLY TO INSURANCE CARRIER OR CLEARINGHOUSE FOR REVIEW
ELECTRONICALLY
2.
Describe two ways electronic claims can be submitted. SUBMITTED DIRECTLY TO INSURANCE CARRIER OR CLEARINGHOUSE FOR REVIEW ELECTRONICALLY 3.
Describe direct billing. WHEN THE INSURANCE CARRIER ALLOWS THE PROVIDER TO SUBMIT CLAIMS ELECTRONICALLY
4.
Explain the role of a claims clearinghouse.
MOA115 Medical Records and Insurance Week
5 Assignment – Reimbursement Concepts IT’S A LINK BETWEEN THE INSURANCE COMPANY AND THE HEALTHCARE FACILITY. THEY AUDIT AND REFORMAT CLAIMS TO THE INSURANCE COMPANIES SPEECIFICATONS
E. Completing the CMS-1500 Health Insurance Claim Form 1.
The medical assistant obtained precertification for a procedure. After the procedure was completed, what are six items needed to complete the CMS-1500 Health Insurance Claim Form? a.
PATIENT HEALTH RECORD
b.
INSURANCE CARD INFO
c.
ENCOUNTER FORM
d.
INSURANCE CLAIM PROCESSING GUIDLINES
e.
PATIENT REGISTRATION FORM
f.
PRECERT INFO
2.
Name the three sections of the claim form. a.
CARRIER
b.
PATIENT AND INSURED INFO
c.
PHYSICIAN OR SUPPLIER INFO
3.
Identify information required to file a third-party claim. a.
What information must be included in Section 1 of the claim form? TYPE OF INSURANCE
b.
Name 13 pieces of information required in Section 2. 1.
INSURED ID NUMBER
2.
PATIENT FULL NAME
3.
PATIENT DOB/GENDER
4.
INSUREDS NAME
5.
PATIENTS ADDRESS/TELEPHONE NUMBER 6.
PATIENT RELATIONSHIP TO INSURED
7.
INSURED’S ADDRESS AND PHONE NUMBER
8.
SECONDARY INSURANCE NAME
9.
SECONDARY INSURANCE INFO
10.
PATIENTS CONDITION RELATED TO WORK ACCIDENT OR OTHER
11.
PRIMARY POLICY GROUP OR FECA NUMBER
12.
PATIENTS RELEASE OF INFO
13.
INSURED AUTHORIZATION OF BENEFITS
a.
Name 19 pieces of information required in Section 3 1.
PROVIDER SIGNATURE
MOA115 Medical Records and Insurance Week
5 Assignment – Reimbursement Concepts 2.
ADDRESS OF THE FACILITY
3.
TOTAL CHARGES
4.
ASSIGNMENT ACCEPTED
5. PATIENTS ACCOUNT NUMBER WITH TREATING PROVIDER
6. NPI OF PROVIDER 7.
PROVIDERS EIN OR SSN
8.
ADDITIONAL CLAIM INFORMATION
9.
CPT/HCPCS CODES, PLACE OF SERVICE, DIAGNOSIS REFERENCE,
CHARGE AMMOUNT 10.
DATE OF CURRENT ILLNESS
11.
IF PATIENT HAS HAD SAME OR SIMILAR SYSTEMS
12.
FROM-TO DATES IF PATIENT IS UNABLE TO WORK 13.
NAME OF REFERRING PROVIDER AND NPI
14.
FROM-TO DATES IF PATIENT ENCOUNTER INCLUDED INPATIENT HOSPITAL VISIT 15.
WHETHER AN OUTSIDE LABORATORY WAS USED 16.
ICD-10-CM DIAGNOSIS
17.
REFERENCE TO POSSIBLE PRIOR MEDICAID CLAIM 18.
PRIOR AUTHORIZATION 19.
FROM-TO DATES OF CURRENT ENCOUNTER
F. Accurate Coding to Prevent Fraud and Abuse 1.
Differentiate between fraud and abuse. FRAUD IS CONSCIOUS INTENT TO DEFRAUD AN ENTITY, ABUSE IS AN INADVERTANT OR
UNETHICAL ACTION
2.
What are the possible consequences of coding fraud and abuse? NONPAYMENT OF CLAIMS, MONETARY PENALTIES, CRIMINAL CIVIL LIABILITY, JAILTIME
G. Checking the Status of a Claim 1.
Insurance companies will typically take 30
days to process insurance claims electronically. 2.
What information is needed to verify the claim status with insurance company? INSURANCE NAME, PHONE NUMBER, CLAIM ADDRESS
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