Medical billing insurance card terms and definition - ID format

INSURANCE CARDS ID FORMAT

Insured Name – Should always be set up EXACTLY as it appears on the card.  This is especially important since Medicare and Medicaid will deny if the name on the claim sent does not match the name on the card.

Group, Policy and ID#’s – Should be entered WITHOUT any dashes.  Example: policy# 475-70-5040 would be entered as 475705040.

Blue Cross/Shield – For Federal plans where ID begins with “R” and outstate plans that have an alpha prefix before the ID (example:  XZA475705040) claims are filed to your home plan.  For non-prefixed ID’s (example: 475705040) claims would go to the Blue Cross/Shield plan specified on the card.  It is very important that the employer and group are included in the registration.

PPO vs. NON-PPO –
If you belong to the PPO, claims are submitted to them.  If not, the cards should indicate where to send the Non-PPO claims.  Examples:  Wynnewood Refining Company, PPO Claims go to PPO Oklahoma, Non-Network claims go to Gallagher Benefit Administrators.  Mid-South Iron Workers, PPO claims go to CompMed Physicians, Non-Network claims go to Zenith Administrators. 

Worker’s Compensation Claims –
Always try to obtain the worker’s compensation claims information and send the claims to them, rather than an employer.  There are a few unscrupulous employers who will have the bill sent to them and then have never filed the claim and fail to reimburse the facility.

Auto Insurance - Auto accident information should be entered even if the patient was not at fault or does not have auto insurance in case litigation is warranted.  Any information entered, even in notes, can be helpful.  Auto accidents can take many years to reach a settlement and documentation taken near the time of the accident can be critical to the site being reimbursed for treatment costs.

Tribal Self-Insurance – Even though it is not billable for Federal IHS sites, the information still needs to be entered and adjusted off for cost accounting purposes.  Contract Health Services needs this to coordinate benefits.

Dental, Pharmacy, Vision, and Mental Health Insurance – Often, if patient has dental, pharmacy, vision or mental health insurance coverage, a different company is administering the benefits, not the medical insurance carrier.  The ROI/AOB and MSP are conditions of participation (CoP) in the Mcare program.

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