Filing the Claim Form

1
Chapter 14

• Filing the Claim Form

2
Health Insurance Plans

• Employer-sponsored private plans
• Insurance plans
• Medicare
• Medicaid
• Health maintenance organizations

3
Health Insurance Plans (cont.)

• Individual policies
• Workers Compensation
• CHAMPUS, CHAMPVA, TRICARE

4
Insurance Reimbursement

• Fee-for-service
• Capitation
• Episode-of-care
• Coordination of benefits

5
Insurance Claim Form

• CMS-1500
• May be submitted electronically or on paper to
  the carrier
• Printed using red ink and scanned upon receipt by
  the carrier using optical character recognition
  (OCR)

6
Common Claims Errors

• Missing place of service
• Missing type of service
• Incorrect or missing dates of service
• Incomplete provider information

7
Charge and Payment Verification

• Deductible
• Co-payment
• Coinsurance
• Explanation of benefits (EOB)

8
Medicaid

• Provided to medically indigent, low-income
  individuals and families, supplement to disabled
  persons on SSI, and persons receiving
  institutional or nursing home care
• All other insurance is considered primary
  Medicaid is always secondary.

9
Medicare

• Covers retired people 65 or older, people with
  end-stage renal disease, and those receiving
  disability benefits (SSDI)

10
Health Maintenance Organizations

• Managed care concept the payer manages,
  negotiates, and contracts for health care while
  keeping costs down

11
CHAMPUS

• Civilian Health and Medical Program
• CHAMPUS expanded into TRICARE to standardize
  benefits and to control health care costs for
  military personnel and dependents.

12
TRICARE

• Defense Enrollment Eligibility Reporting System
  (DEERS)
• TRICARE Prime
• TRICARE Extra

13
CHAMPVA

• Civilian Health and Medical Program of the
  Veterans Affairs
• Covers expenses of dependent spouses and children
  of veterans with total, permanent,
  service-connected disabilities or of spouses and
  children of veterans who died in the line of duty

14
Workers Compensation

• Covers on-the-job accidents, injuries, and
  illnesses related to employment
• Premiums are paid by employers to a statewide
  fund to cover expenses and portions lost wages
• Five principle types

15
Blue Cross/Blue Shield

• Two types of policies
• Service benefit
• Indemnity benefit
• Payment methods
• Usual, customary, and reasonable (UCR)
• Relative value scale (RVS)
• Diagnosis-related groups (DRG)

16
Electronic Claims Processing

• Preparation, generation, and submission of
  claims electronically
• HIPAA standards

17
Insurance Claims Follow-up

• Problem claims