Electronic claim submission - Medical billing


Providers must use good faith effort to bill Insurance for services with the most current CMS approved diagnostic and procedural coding available as of the date the service was provided, or for inpatient facility claims, the date of discharge. The following information must be included on every claim:

** Institutional Providers:

o The completed UB 04 data set or its successor format adopted by the National Uniform Billing Committee (NUBC), submitted on the designated paper or electronic format as adopted by the NUBC. Entries stated as mandatory by NUBC and required by federal statue and regulations and any state designated data requirements included in statues or regulation.

** Physicians and Other Professional Providers:

o The Centers for Medicare and Medicaid Services (CMS) Form 1500 or its successor adopted by the National Uniform Claim Committee (NUCC) submitted on the designated paper or electronic format. Current Procedural Terminology (CPT) codes and modifiers and International Classification of Diseases (ICD) codes. Entries states as mandatory by NUCC and required by federal statute and regulation and any state designated data requirements included in statutes or regulations.

The following information must be included on every claim:

** Patient name, date of birth and ID number

** Patient gender and address

** Date(s) of service for each service rendered

** Other insurance information, as applicable

** Valid ICD-9 diagnosis and procedure codes

** Valid ICD-9 diagnosis pointers

** HIPAA-compliant CPT, HCPCS and modifier code sets

** Billed charges for each service line

** Total billed charges for the claim

** Place and type of service code

** Units, as applicable (anesthesia claims require minutes)

** Provider federal tax identification number

** 10-digit National Provider Identifier (NPI) (All claim fields that requires provider identification)

** Rendering provider name

** Service facility location information

** Billing/pay-to provider name and address

** For prenatal or delivery services, the last menstrual period (LMP) date is required

** 11-digit National Drug Code (NDC) number is required for HCPCS codes in the J series; HCPCS codes in the Q or S series that represent drugs; CPT codes in the 90281-90399 series (immune globulins); and Enteral Nutritional B Code Products that price AWP (B4157-B4162)ELECTRONIC CLAIM SUBMISSION

Molina Healthcare accepts claims electronically, including secondary claims.

** Web-Portal (www.MolinaHealthcare.com) Provider Self-Services

o Register today to access our on-line services. A video will guide you through the easy online registration process.

** Submit claims

** Status claims

** Print claims reports

o If you experience any problems with the Provider Self Services website, please contact Molina Healthcare’s Help Desk at 1-866-449-6848 for technical assistance or call your Provider Services Representative directly.

** Emdeon - Electronic Data Interchange (EDI) Gateway Partner

o Emdeon accepts all electronic claims (837P/837I) on behalf of Molina Healthcare. As a provider, you may continue to submit claims to your existing EDI clearinghouse: they will forward your files to Emdeon.

o Providers billing Molina Healthcare electronically should use payer number 20149.

o If you experience any problems with your transmission, please contact your local clearinghouse representative.

For additional information, go to Molina Healthcare’s EDI website - www.MolinaHealthcare.com. Molina Healthcare encourages electronic claim submission as it provides your office with the following benefits:

** Reduces operational costs associated with paper claims
** Reduces time for Molina Healthcare to receive a claim by eliminating mailing time
** Increases accuracy of data
** Ensures HIPAA compliance

Track your electronic transmissions using acknowledgement reports to ensure that claims are received for processing in a timely manner. When your claims are filed electronically you will:

** Receive an acknowledgement from the clearinghouse.

** Receive an acknowledgement from Emdeon within 5-7 business days of your transmission.

Registration is easy. Follow these simple steps:

1. Visit https://providernet.adminisource.com and select Register
2. Verify your information

a. Select Molina Healthcare from the payers list

b. Enter your primary NPI, Tax ID and a recent check number associated with the NPI/Tax ID combination

3. Enter your User Account Information and use your email address as you user name
4. Verify your Contact Information, Bank Account Information and Payment Address
a. Note: Any changes to this address may interrupt the EFT process
5. Sign and return the ACH form with a voided check from your registered account immediately
6. Add any additional payment addresses, accounts, and Tax IDs once you have logged in.

Once your account is activated, you will begin receiving all payments through EFT, and you will no longer receive a Paper EOP (i.e. Remittance) through the mail. You will receive 835’s (by your selection of routing or via manual download) and have the ability to view, print, download, and save historical and new ERA as of payment date March 28, 2011, and forward.

Filing claims electronically is a good way to improve the practice revenue. Now a days all the software vendor and all major insurance accept the Electronic claims.

Payor id is a number which is assigned for one particular insurance which is similar to e-mail id. Get the payor id and update it in your system and submit the claims electronically. Contact your software vendor and clearinghouse for more details.

Advantages of electronic claim submission

1.Faster claims prepartion.
2.Clerical error minimized.
3.No postage costs.
4.Faster claim processing.
5.Reduced paperwork.
6.Acknowledgement report and rejection report.
7.Tracking of the claims are very easy.

Electronic claim VS Paper Claim

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