Medical Billing Concept - Enrollment process

The first process - Enrollment process


Provider Enrollment is the crux of a proper billing setup. Before we send claims to insurance companies, we should ensure that all provider (doctors) are enrolled with the respective carriers, all providers are contracted.

The process is as follows:

For Federal carriers such as Medicare and Medicaid, we need the provider # to submit claims. Otherwise they would get denied. In order to get this; we need to act at the inception itself.

When a new provider has joined the group, we need to ensure the following:

· Does the provider have all the credentials?
· Does the provider have a State License? Without State License the doctor cannot perform in that State.
· Does the provider have a contract with major carriers in the State? If so we can just write a letter to the carrier saying that this provider has joined the group and request them to merge the provider with the group.

Where the provider does not have a contract with a carrier, a fresh application for enrollment is required.

A Fresh application in Form 855 is filled and signed by the doctor and sent to the carrier. This form should be filled up with details such as the doctor’s name, his Social Security Number (SSN), his State License Number, the name and address of the facility in which he is or will be providing services, the name and address of the group of which he has become a member, the name of the owner of the group, the pay-to address of the group etc.

The carrier processes it and sends in intimation mentioning the provider #. This provider # becomes the individual provider # for that doctor and needs to be stated in Box 24K and Box 33-PIN # in the CMS.

Box 33 of the CMS also contains the Pay-to address where the checks and EOBs need to be sent by the carriers. But Medicare and Medicaid do not go by what is mentioned in this box with regard to pay-to address. Based on the pay-to address mentioned in Form 855 at the time of enrollment the carrier records it in its system. All checks and EOBs will be sent to this address. If there is a change of address, the carriers need to be notified in Form 855-C. Based on this, the carriers update this information in their system.

In this regard the following terms need to be understood:

Employer Identification Number (EIN): This is a tax identification (tax id) number of the group into which the doctor has joined. This number is allotted by the IRS for the purpose of submitting the tax returns. The group needs to show this number in all claim forms and correspondence with the carrier.

W-9 Form: This is a “Request for tax payer identification number and certification” form. This shows the provider’s individual tax id # (SSN) or the group tax id # (EIN) along with the pay-to address. This can be used for updating the tax id # and the pay-to address with the carriers. This should be signed by the provider.

EDI Enrollment

EDI is Electronic Data Interchange. Certain carriers have the facility to accept claims electronically. For this purpose we need to enroll the providers with the EDI Department of the insurance carriers. This is mandatory requirement in the case of Federal Carriers such as Medicare and Medicaid. This is a separate process apart from the above Provider Enrollment process. We need to fill in a separate EDI enrollment form for providers and send them to the carrier. The carrier will then add the provider in the EDI database. Only then can we submit claims to that carrier for that provider electronically.

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