Medical Billing Process - Claims Generation and Transmission

cliam submisstion process

The next step after demographics and charge entry is claims generation. Claims may be paper claims or electronic claims.

A claim is a comprehensive pooling of all data relating to a patient for a particular treatment. All registration, charges and provider information is contained in this form which is sent to the insurance carrier for processing. The data presented in this form should be 100% accurate since payment or otherwise to the doctor for the patient’s treatment is based on the information provided in this form. Hence this should be thoroughly audited before sending to the carriers.
Paper claims
There are various types of forms for paper claims. The most widely used form is HCFA-1500 designed by the Health Care Financing Administration. This is a red color form in white background. The other forms used by specific carriers are UB92, Green-and-white form for NY Medicaid, Georgia Medicaid Form 8 etc. These forms are set up in the billing system that you are using in order to enable you to print directly from your system.

Proper filling up of all required fields in the HCFA-1500 is the most essential function of a billing company. Attached are the basic instructions in filling up each field in HCFA-1500 and a copy of the HCFA-1500.

Once the claims are generated and printed, they should be packed and sent to the carriers. We need to use proper window covers for this purpose.

The red HCFA-1500 forms are designed for OCR (Optical Character Recognition) scanners. When the computer printed HCFA runs through the scanner (around 2400 claims per hour can be processed), it stores in the computer all the data available in the HCFA. This eliminates data entry by the insurance processing staff on receipt of the HCFA. This is the reason why HCFA should be properly aligned (all fields should be printed in proper places) while printing. The following precautions should be taken while printing:
--- Use the most common type of font.--- Use only black inked impressions--- Print only in the white areas. Any prints in the shaded areas will not be OCRd.---- Use only UPPER cases.---- Do not erase or use correction fluid after printing. If there is an error, print a new HCFA.---- Do not highlight.---- Fold only at the proper places.----- Above all the print quality should be clear and alignment should be perfect.

claim submission tip - do it everyday

Electronic Transmission

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company’s computer system or to the clearing house.

The major advantages of this method are less administrative costs, no concerns of claims being lost in transit, no concerns regarding data entry errors being made by insurance staff while processing claims, less rejections, less turnaround time between the process of data and process of claim by the carrier and above all we can receive reports of the number of claims sent and received by the carriers.

Medicare pays electronic claims within 14 days while paper claims take 27 days in processing. In some cases there is a facility for Electronic Fund Transfer (EFT) wherein the carriers deposits the check directly into the bank account of the provider or the group. Here again the number of days it takes to send the check through post and then manually depositing them into the bank is avoided.

For Federal Carriers, in order to transmit claims electronically, we need to enroll the providers through EDI of that carrier. These carriers have facility of transmission directly and not through any clearing house. Certain other carriers also have the facility of accepting electronic claims, but they have to send through a clearing house.

For this purpose we need to establish vendors (Clearing House) who has the facility of receiving claims from the billing office, performs edit checks which are more or less equal to the carrier requirements and has numerous carriers registered under it for forwarding claims electronically.

These vendors accepts data in a single format and edits, sorts and distributes the data into formats that are acceptable by various plans. They charge a fee that is generally a fixed amount per claim.

1 comment:

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