Filing Steps for Managed Care Par and/or Non-Par or Major Medical
Step 1. Copy patient's insurance card, front & back and copy his or her driver's license for positive proof of medical records and identification.
Step 2. Determine if the treating doctor is a participating provider with this plan.
Step 3. Determine if the patient is the insured or a dependent and if they have primary and secondary coverage(s).
Step 4. Determine if the coverage (policy) is from a fully-funded, self-insured, or managed care group.
Step 5. Call the insurance company and ask for benefits for chiropractic care. Clarify where claims should be mailed and if any special claim forms or applications are required. Some plans can also be verified online.
Step 6. Verify the effective date, and possible expiration date, of the insurance policy.
Step 7. Verify possible exclusions and policy limitations on such things as: diagnosis, treatment, number of visits, and dollar value of coverage; as well as deductible and co-pay.
Step 8. If the doctor is non-participating, inform the patient that all charges are his or her responsibility regardless of coverage and that all disputes of non-coverage should be handled between the patient and the carrier. If the doctor is participating, know the fee schedule, copayment and write-off amounts.
Step 9. If necessary, have the patient sign an "assignment of benefits" form and an "office policy regarding accepting assignment." Participating doctors do not need an assignment of benefits signed.
Step 10. Confirm that the diagnosis listed on the claim form supports all services billed, and that the documentation justifies each code used. Do not bill for services that are not documented in the patient's chart. Remember, "Not documented, not done!"
Step 11. If filing electronically, download information to clearing house at the end of each day.
Step 12. If filing paper claims, file at least once a week.
Step 13. Know the filing deadlines for each case: 30 days, 45 days, 95 days, 10 months and 1 day, and 1 year are all common depending on the carrier, the state in which you practice, or where the patient is insured.
Step 14. If filing electronically, make sure you know the carrier’s EDI payor number for the clearing house.
Step 15. If the patient has been referred to you, you will need to know the referring doctor’s NPI number.
Filing Step by Step -- Medicare
Step 1. Know if you are a "participating" or "non-participating" provider.
A. participating=contractually accepts assignment on all Medicare patients
B. non-participating=may accept assignment, or not, on Medicare patients
Step 2. Know if Medicare is primary or secondary, (these instructions are for primary). If Medicare is secondary, and you bill your normal charges to the primary payer and accept that amount as payment in full (collecting nothing from the patient, i.e., PIP), then you bill nothing to Medicare. If you plan on collecting money from the patient, (co-payments and/or deductibles), then you use your Medicare fee--for the Medicare covered service--and bill to Medicare after the primary has paid.
Step 3. Know the amount that you may legally charge for the level of CMT code used.
A. participating=allowable=par amount*
B. non-participating, no assignment=limiting charge=limiting amount*
C. non-participating, assignment=non-par allowable= non-par amount*
*minus any “fines” from PQRS and/or EHR reporting
Step 4. Know the patient's Medicare identification number (complete with letter), (not always his/her SS#). NOTE: Starting in 2018, Medicare will no longer use SS# for ID numbers.
Step 5. Medicare requires documentation of medical necessity in SOAP notes. Since x-rays are no longer required (01/01/00), an examination must be documented to indicate the somatic/segmental dysfunction diagnosed using the P.A.R.T. (Pain/Asymmetry/Range of Motion/Tissue tone or tenderness) format, two of the 4 items must be documented with one being either the A or the R.
Step 6. The primary diagnosis must be of a segmental dysfunction, M99.0__ code(s). There must be an active symptom associated with the subluxation to justify the service as "medically necessary." When diagnosing several regions (C/T/L), you must diagnose the segmental dysfunction, then the symptom that relates to that region. Use only ONE symptom per region. Link the adjustment code to “A” only. You may list all diagnoses in the medical record.
Step 7. The only reimbursable service is CMT codes for manipulation. You do not need to file for "non-covered" services unless the patient asks you to do this for purposes of a denial for secondary policies. You may use the proper CPT code, with the modifier “GY” on all non-covered services. NEVER BILL CODES 97010 (hot & cold packs) or 99070 (supplies) to Medicare.
Step 8. There must be documentation for the medical necessity of the service in the patient's chart, in the form of SOAP/PART notes.
Step 9. The onset date in box 14 of the claim form, is the first adjustment for that incident. Make sure to document the incident completely and do a P.A.R.T. exam for the medical records.
Step 10. Providers are always required to file a Medicare claim for the patient (beneficiary). Patients cannot file their own claims. Even non-par, non-assigned claims must be filed by the provider. Mandatory filing is ONLY exempt if the patient signs an ABN and choses option 2.
Filing Steps and Questions to ask for Auto Accidents
Step 1. Identify the vehicle the patient was riding in at the time of the accident:
A. their own vehicle - does the patient have PIP/Med pay coverage?
Yes: file as primary regardless of liability
No: check for Major Medical policies to file (may subrogate liability)
B. riding with a friend - is the vehicle covered by a policy with PIP/Med Pay?
Yes: file to vehicle's policy as primary
No: check for personal PIP/Med Pay coverage
C. borrowed car - is the vehicle covered by a policy with PIP/Med Pay?
(make sure they are an "authorized" driver under the policy)
Yes: file to vehicle's policy as primary
No: check for personal PIP/Med Pay coverage
D. rented car - was there special coverage taken out under the rental?
Yes: file to rental insurance coverage
No: check for personal PIP/Med Pay coverage
E. work vehicle - is this a Workers' Compensation Claim?
Yes: file to Workers' Comp carrier
No: check for a company "liability" policy on commercial vehicles
Step 2. Once the primary carrier has been identified, check to see if there are any secondary policies that may be used once the primary coverage has been exhausted.
Step 3. Notify the patient that all charges incurred will be his or her responsibility regardless of coverage(s), liabilities, or settlements unless the doctor is a provider with an involved insurance plan.
Step 4. Make sure the patient has applied for benefits with primary payer by filling out an "Application for Benefits." (Doctors may also have to fill out a "physician's report" before claims will be paid.)
Step 5. Have patient sign an "Agreement" letter. Have adjuster and attorney co-sign the same "Agreement" letter.
Step 6. Verify with adjuster that the "Agreement" letter has been accepted and that claims will be paid directly to your office.
Step 7. Make sure primary diagnosis reflects trauma and complete diagnosis supports treatment plan and diagnostics ordered.
Step 8. Check every claim for accident related care and mail claims to primary payer at least once a week.
Step 9. Follow-up on unpaid claims within 15 days. PIP, in some states, only has 30 days to pay.
Step 10. Make sure the patient is not insured with a managed care plan that the treating doctor is a provider for, this may reduce the amount of money the 3rd party payer will pay.
Claims Checklist
What CPT (Current Procedural Terminology) procedure codes were billed?
_____ have you used them correctly?
_____ have you documented them correctly?
_____ have you established "clinical rationale" for codes used?
_____ have you used the right codes for the carrier?
_____ have you used HCPCS codes instead of CPT codes when required?
What are the ICD10 (International Classification of Diseases, vol 10)diagnosis codes that were billed?
_____ have you used them correctly?
_____ have you documented them correctly?
_____ have you established "clinical rationale" for codes used?
_____ have you use the correct codes for that carrier?
_____ have you listed the codes in the correct order on the claim?
What are the laws that govern that insurance policy?
_____ are there state or federal laws to consider?
_____ are there any deceptive trade practices laws?
_____ are there any Board of Chiropractic Examiners’ rules?
_____ are there Workers' Compensation rules on this claim?
_____ are there any Medicare/Medicaid statutes and rules to consider?
_____ are there any managed care contract language restrictions/rules?
FAST RULES TO LEARN
Special circumstances to consider (claim form requirements & rules):
- auto accidents
*PIP:usually no subrogation, assignable, pays in 30 days
*Medpay: usually assignable, must be paid back if another liable
*Liability: pays at end of care, do not file until patient is released
*Attorney: wants ‘statement,’ pays at end of settlement, need LOP
- liability other than auto
*home owners:consider cash only
*"slip & falls": consider cash only
- workers' compensation
*subscribers:must participate in managed care type program
*self insured (non-scribers): employer pays, but no guarantees
*federal: not good coverage for chiropractic, consider referring
- Medicare: must have PTAN to treat, must bill for patient
- Medicaid: do not have to be a provider, if accept as patient – no money
- fully funded major medical:follows state insurance laws
- self-funded managed care: (ERISA) follows federal laws
- contracted managed care: in-network, must bill for patient and accept fees set by carrier, cannot accept patient as a cash patient for any service
- preventative care:must not have an injury or illness dx code, use Z codes
Patient Contact Information
First NameM.I.Last NameID#
Sex D.O.B. Social Security Number--
Address
CityStateZipCell ( ) ______-______
Please list the phone numbers in order which you wish to be contacted:
- (_____) _____-______home / office / cell – leave message YES / NO
- (_____) _____-______home / office / cell – leave message YES / NO
- (_____) _____-______home / office / cell – leave message YES / NO
- ______email address
If it is OK to leave a message at the above phone number(s) on a voice message machine or with a person who may answer the phone at this number, please circle Yes or No.
Primary Insurance
Insurance Carrier ID #
Insured Name ______Relationship ______
Do you have a Secondary Insurance Carrier ______
Secondary Insured ______ID #______
Employer
Current Employer
AddressCityState
ZipGroup # Phone ()-
Is this injury a:
____ Auto Accident____ Work Comp InjurySlip/FallOther
Date of Injury______/______/______Attorney Information:
Time of Injury______:______am ____pm
Date of 1stTx______/______/______