MOA115 Medical Records and Insurance

Week 5 Assignment – Reimbursement Concepts

Chapter 15 Medical Billing and Reimbursement Essentials

A. Types of Information Found in the Patient’s Billing Record
1. The patient’s billing record information is often found on the patient registration form.
Using Figure 15.1 in the textbook, list the billing information found on the patient
registration form.
Patient information, Insurance ID, Group number ,Effective date
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B. Managed Care Policies and Procedures
1. What items should the medical assistant gather when using the paper method to obtain
a precertification for a service or procedure?
Patient health record, prior authorization (precertification) request form, copy of patient's health insurance ID card, a pen.
________________________________________________________________________
________________________________________________________________________
2. Describe the processes for precertification using the paper method. What does the
medical assistant need to do?
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Gather the health record, precertification/prior authorization request form, copy of the health insurance ID card, and a pen. Complete the Precertification/Prior Authorization Request form using a pen.

________________________________________________________________________
Proofread the completed form and make any revisions needed. File the document in the health record after it is faxed to the insurance carrier.

3. Describe the managed care requirements for a patient referral.

A pre authorized needs to be obtained for a referral and an hard copy of the authorized
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referral must be sent to the PCP's office before the referral can be approved
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C. Submitting Claims to Third-Party Payers
1. In your own words, identify the steps for filing a third-party claim.
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photocopy of the patient's insurance card check the chart to see whether the patient signature is on file for release of information and assignment of benefits.

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complete boxes 1 to 3 complete boxes with patient and insured information complete boxes with physician or supplier information.Forward the completed claim to clearinghouse.

D. Generating Electronic Claims

1. Describe the electronic claim form.
CMS-1500 submitted either directly to insurance carrier or clearinghouse for review electronically
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2. Describe two ways electronic claims can be submitted.
Direct billing to the insurance company Clearinghouse submission
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3. Describe direct billing.
Which an insurance carrier allows a provider to submit insurance
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claims directly to the carrier electronically
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4. Explain the role of a claims clearinghouse.
acts as an intermediary between the healthcare facility and the insurance company audits
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claims for completeness reformats them to insurance company's specifications
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 MOA115 Medical Records and Insurance
Week 5 Assignment – Reimbursement Concepts

E. Completing the CMS-1500 Health Insurance Claim Form

1. The medical assistant obtained precertification for a procedure. After the procedure was
completed, what are six items needed to complete the CMS-1500 Health Insurance
Claim Form?
Patient health record
a. __________________________________________________________________
patient insurance card information
b. __________________________________________________________________
encounter form
c. __________________________________________________________________
insurance claim processing guidelines
d. __________________________________________________________________
patient registration form
e. __________________________________________________________________
precertification information
f. __________________________________________________________________
2. Name the three sections of the claim form.
carrier
a. __________________________________________________________________
patient and insured information
b. __________________________________________________________________
physician or supplier information
c. __________________________________________________________________
3. Identify information required to file a third-party claim.
a. What information must be included in Section 1 of the claim form?
The type of insurance
__________________________________________________________________
__________________________________________________________________
b. Name 13 pieces of information required in Section 2.
1. insured's ID number
______________________________________________________
2. patient full name
______________________________________________________
3. patient date of birth and gender
______________________________________________________
4. insured's name
______________________________________________________
5. patient's address and telephone number
______________________________________________________
6. patient relationship to insured
______________________________________________________
7. insured's address and phone number
______________________________________________________
8. secondary insurance name
______________________________________________________
9. Secondary insurance information
______________________________________________________
10. patient's condition related to work, accident or other
______________________________________________________
11. primary policy, group, or FECA number
______________________________________________________
12. patient release of information
______________________________________________________
13. insured authorization of benefits
______________________________________________________
c. Name 19 pieces of information required in Section 3
1. date of current illness
______________________________________________________
2. whether the patient has had same or similar symptoms
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3. From-To dates if the patient has been unable to work
______________________________________________________
4. name of referring provider and NPI
______________________________________________________
5. From-To dates if patient encounter included inpatient hospital visit
______________________________________________________
6. additional claim information
______________________________________________________
7. whether an outside laboratory was used
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 MOA115 Medical Records and Insurance
Week 5 Assignment – Reimbursement Concepts

8. ICD-10-CM diagnosis code

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9. reference to possible prior Medicaid claim
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10. prior authorization
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11. From-To dates of current encounter
______________________________________________________
12. CPT/HCPCS codes, place of service, diagnosis reference, charge amount
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13. NPI of provider
______________________________________________________
14. provider's EIN or SSN
______________________________________________________
15. patient's account number with treating provider
______________________________________________________
16. assignment accepted
______________________________________________________
17. total charges
______________________________________________________
18. address of the facility
______________________________________________________
19. provider signature
______________________________________________________
F. Accurate Coding to Prevent Fraud and Abuse
1. Differentiate between fraud and abuse.
Fraud is the intentional deception or misrepresentation that an individual knows to be false
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Abuse are actions that are inconsistent sound medical, business, or fiscal practices.
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2. What are the possible consequences of coding fraud and abuse?
Some possible consequences of coding fraud and abuse is mprisonment, tarnishing healthcare providers'
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regulation and damaging their patients' trust.
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G. Checking the Status of a Claim
1. Insurance companies will typically take ______ 10-14 days to process insurance claims
electronically.
2. What information is needed to verify the claim status with insurance company?
the patient's insurance ID, policy number, coverage period, co-payment requirements, deductibles
________________________________________________________________________
,________________________________________________________________________
deductibles, and pre-authorization requirements.