chapter 11 medicare medical billing
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Comprehensive Health Insurance
Billing, Coding, and Reimbursement
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Chapter 11Medicare Medical Billing
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Administration
Centers for Medicare and Medicaid Services (CMS)
Purpose: To serve as a consolidated agency for Medicare and Medicaid
CMS and Social Security Administration (SSA)
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Part A Eligibility
65 or older Adult with disability Disabled before age of 18 Entitled individuals’ spouses End-stage renal disease (ESRD)
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Part A Coverage
Inpatient hospital care: 90 days in a benefit period with 60-day lifetime reserve
Skilled nursing facility: 100 days during a benefit period
Home health care: Part time or intermittent skilled nursing care, home health aide, and therapies along with DME
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Inpatient Benefit Days
Benefit period: Time during which medical benefits are available
Basic days: First 60 days of acute inpatient care
Coinsurance days: Days after first 60 days
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Inpatient Benefit Days
Lifetime reserve days: Start after basic days and 30 coinsurance days in one benefit period
Skilled nursing facility days: No coinsurance for first 20 days then $124 per day for days 21 through 100 of each benefit period
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Part B Eligibility
Meet requirements for Part A Purchase Part A Part B purchase: Based on annual income Meet deductible: Yearly
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Noncovered Services Medicare Part A and B
Routine services Screening tests and/or screening
laboratory tests Dental care See the full list in your student textbook,
page 323.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Providers
Part A: Hospitals, skilled nursing facilities, nursing homes, and home health and hospice agencies
Part B: Physicians, nonphysician practitioners, or suppliers who have an agreement with Medicare.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Part C (Medicare + Choice)
Established in 1997: Same benefits as part A and B
Now Medicare Advantage Plus Additional benefits: Hearing aids,
dentures, and prescription drugs Types of plans
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Part D
Prescription drug coverage Eligible for Parts A and B Premium required
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medigap
Authorized insurance companies Secondary payer Not available to HMO participants Regulated by Medicare law Crossover: Reassignment of coverage gap
to Medigap policy
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medical Necessity
Procedure must match diagnosis Nonexperimental or investigational
procedures Essential treatment Appropriate delivery level
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Participating Providers
Contract with Medicare Benefits
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Nonparticipating Providers
Accepting assignment– The nonparticipating provider must still file all
Medicare claims on behalf of the beneficiary, accept a 5% lower fee allowance for services, understand that Medigap/supplemental insurance does not automatically cross over, and does not have access to beneficiary eligibility information.
Not accepting assignment– Payment is sent to the beneficiary.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Patient’s Financial Responsibility
Par provider accepting assignment: 20% of MFS
Non-par provider accepting assignment: 20% of non-par provider’s MFS
Non-par provider not accepting assignment: Responsible for limiting charge
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Patient Registration
Copy the Medicare card. Obtain patient signatures. Determine primary and secondary payers;
see the extensive list on pages 333–337 of your student textbook.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Billing Requirements—HCPCS
Level I codes: CPT-4, procedures Level II codes: Supplies and services and
dental procedures Level III codes: Reserved for use by
regional carriers
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Completing Medicare Part B Claim Forms
CMS-1500 (paper) EMC (electronic) is preferred. Information is entered into the form
locators. All forms must be accurately completed,
whether using the paper CMS-1500 or EMC using a computer, modem, and approved billing software (NSF/ANSI).
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Completing Medicare Part B Claim Forms
All paper forms are sent to Dallas, Texas. Care must be taken to send the claim to
the correct post office box for the region where the services were rendered
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Fraud
Definition: “Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program”
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Fraud
Fraud scenarios: See student text pages 351–352.
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Other Types of Medicare fraud
Using an incorrect or invalid provider number in order to be paid at a higher rate
Selling or sharing Medicare claim numbers in order to facilitate the filing of false claims
Waiving deductibles and/or copayments without attempts to collect such monies due or when the patient is unable to pay
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Other Types of Medicare fraud
Falsifying information on any document filed with the government
Offering or soliciting bribes, rebates, or kickbacks
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicare Abuse
Definition: “Abuse may, directly or indirectly, result in unnecessary costs to the Medicare or Medicaid program, improper payment for services which [sic] fail to meet professionally recognized standards of care, or that are medically unnecessary…”
Abuse scenarios: See student textbook page 353.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Protection Against Medicare Fraud and Abuse
Provider liability for fraud Provider liability for abuse Referring physician liability fraud/abuse Administrative sanctions Education and warning Revoking assignment privileges
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Protection Against Medicare Fraud and Abuse
Withholding payments along with recovery of overpayments
Excluding from Medicare program Posting provider’s name on national
Sanctioned Providers list
Comprehensive Health Insurance
Billing, Coding, and Reimbursement
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Chapter 12Medicaid Medical Billing
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Guidelines for Each State
Establishes own eligibility standards Determines the type, amount, duration,
and scope of services Sets rate of payment for services Administers its own program
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Required Eligibility Groups
Categorically needy Medically needy Special groups
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Categorically Needy
Families who meet state’s aid to families with dependent children eligibility requirements as of July, 16, 1996
Pregnant women and children under age 6: Income must be 133% under federal poverty level
Children ages 6–19 with family income up to 100% of federal poverty level.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Categorically Needy
Caretakers (relatives or guardians) who take care of children under the age of 18 (19 if still in high school)
SSI recipients Persons living in medical institutions with
monthly income up to 300% of SSI standard
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medically Needy
Persons having too much money (as in a savings account) to qualify for categorically needy
Allows states to extend eligibility to additional people
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medically Needy
Spend-down program: Individual is required to spend a portion of their income or resources until below, or at, state income level.
May be highly restrictive: Federal requirements designate who is to be included.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Special Groups
Immigrants: Eligibility is determined at federal level.
Temporary Assistance for Needy Families (TANF): Eligibility is determined at the county level.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Special Groups
State Children’s Health insurance Program (SCHIP): Provides more federal funds to expand Medicaid eligibility to include more uninsured children
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Services Mandated by the Federal Government
Inpatient services Outpatient services Prenatal care Vaccines for children Physician services Nursing facility services for persons 21
years of age and older
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Services Mandated by the Federal Government
Family planning services and supplies Rural health clinic services Home health care for persons eligible for
skilled nursing services Laboratory and x-ray services Pediatric and family nurse practioner
services Nurse midwife services
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Services Mandated by the Federal Government
Federally Qualified Health Center (FQHC) Early and periodic screening, diagnostic,
and treatment services for children under 21 years of age (EPSDT)
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Optional Medicaid Services
Diagnostic services Clinic services Intermediate care facilities for people with
mental retardation
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
PACE (Programs of All-inclusive Care for the Elderly)
Provides an alternative to institutional care for persons age 55 or older who require a nursing facility level of care.
Offers and manages all health, medical, and social services
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
PACE (Programs of All-inclusive Care for the Elderly)
Mobilizes other services: Preventative, rehabilitative, curative, and supportive care
Care is provided in day health centers, hospitals, and nursing homes.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Amount and Duration of Medicaid Services
State may impose limitations. Limitations are restricted by federal
guidelines.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Verification
Always verify patient status prior to seeing the physician
Some electronic verification available Check for restricted status, which requires
the patient to see a specific physician (e.g., PCP) and/or pharmacy.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Claims Filing
Time limits for submitting claims Claims must be submitted within 95 days
from each date of service (DOS). Appeal time limits
– All appeals of denied claims and requests for adjustments must be received within 180 days from the date of disposition, the date of the Remittance and Status (R&S) report on which that claim appears
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Claims Filing
Claims with incomplete information and zero paid claims– Claims lacking the information necessary for
processing are listed on the R&S report with an explanation of benefits (EOB) code requesting the missing information
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Medicaid Claims Filing
Newborn claim hints – When filing a claim for a newborn, if the
mother’s name is “Jane Jones,” use “Boy Jane Jones” for a male child and a “Girl Jane Jones” for a female child. Do not use “NBM” for newborn male or “NMF” for newborn female
Comprehensive Health Insurance
Billing, Coding, and Reimbursement
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Chapter 13TRICARE Medical Billing
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Eligibility
Sponsor: Member of military Beneficiary: Family members of member
of military Service/military retiree: Retired military
service member Uniformed sponsors and family members
must register with DEERS.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Eligibility
A military retiree may remain in TRICARE until age 65.
CHAMPVA beneficiaries are not eligible for TRICARE.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Health Plans
TRICARE Standard TRICARE Prime TRICARE Prime Remote TRICAE Extra TRICARE Senior Prime
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Standard
Fee for service program Annual deductible Covers medical services provided by a
civilian physician Expenses are shared between TRICARE
and the beneficiary. Catastrophic cap
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Prime
Managed care plan Offers additional preventive care Requires enrollment Primary care manager Priority at MTF
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Prime Remote
For active duty members not assigned close to an MTF
Available to family members Same as TRICARE Prime
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Extra
Alternative managed care plan for individuals not having priority at an MTF
Active duty not eligible More expensive than Prime, less
expensive than Standard Annual deductible
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
TRICARE Senior Prime
Age 65 Prescription drug benefit Must be enrolled in Medicare Part A and B No enrollment fee Second payer to Medicare Primary payer if not covered by Medicare
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
CHAMPVA
Administered by the Department of Veterans Affairs
Veterans with 100% service-related disabilities
Spouse is eligible. All services must be approved. Last payer after all insurance and
Medicare
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Submitting Claims
The physician must file a paper claim using the CMS-1500.
The hospital, clinic, or outpatient facility must file a UB-04.
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Submitting Claims
All claims must include the following information:– Patient’s name as it appears on his or her
military ID card– Sponsor’s Social Security number (SSN)– Patient’s date of birth
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Submitting Claims
Other health insurance (OHI) information Appropriate HCPCS, CPT, and ICD-9
codes on CMS-1500 claim forms Appropriate HCPCS, CPT, ICD-9, and
revenue codes on UB-04 claim forms Admitting diagnosis on UB-04 claim forms Care approval number, if applicable Provider’s tax ID number or SSN
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Submitting Claims
Referring physician Rendering physician Beneficiary’s signature (or indicate
“signature on file” if the beneficiary’s signature is on a “release of information” document)
The provider’s or representative’s signature.
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Wisconsin Physicians Service (WPS)
Payer for TRICARE Senior Prime Provider submits claim first After adjudication, claim is sent to WPS.
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Claims for CHAMPVA
Sent electronically through the VA’s clearing house, Emdeon Envoy
Paper claims are submitted to VA Facility Fee Department that authorized the claim.
Paper claims may also be sent to: VA Health Administration Center CHAMPVA, P.O. BOX 65024, Denver, CO 80206–9024.
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Claims for Northern Region of United States
Health Net Federal Services, Inc., Care of Palmetto Government Benefits Administrators (PGBA)
PGBA provides online claims service.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Advantages of Filing Online
Direct transmission to PGBA Immediate acceptance or rejection of
claim Time saving online corrections of claims Processing and payment in a shorter
period of time
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