Submitting Claims

Video Transcription

[MUSIC PLAYING] This lesson, we'll discuss submitting insurance claims in a timely manner. There are three different ways to submit claims. One is paper format, though this method is becoming increasingly rare, through an EHR, or electronic health records system, and last, by submission through a clearinghouse. So let's get into the details of getting claims taken care of. First we'll discuss timely filing, next, claim paperwork, clearing houses, EHRs, and claim submissions.

Timely filing is the phrase used by insurance companies or EAPs when there is a limit on the amount of days within which a claim can be filed. If the claim is not filed within the timely filing period, companies do not have to pay the claim and you cannot bill the client. Timely filing can be from 90 days to one year, depending on the company.

In order to avoid denials for timely filing, it's important to file claims on a weekly or bi-weekly basis. If this is not possible, set aside an entire day for billing every few weeks. The goal of these strategies is to ensure that all filing is timely. Even if a claim is denied for timely filing, a counselor can appeal the denial if there is a good reason for the appeal.

Claim submissions occur on a CMS-1500 form. The CMS-1500 is the universal form used by non-institutional providers to submit claims, whether the claim is electronic or paper. Non-institutional providers include physicians, nurses, or therapists. Institutional providers include hospitals and skilled nursing, and these type of providers, they bill on a UB-92 form.

In paper, the form is read and must be submitted as the read form. A set of 500 forms cost around $20. Although some insurance companies still accept paper claims submitting, the claim via EHR or clearinghouse is the primary way claims are submitted to insurance companies.

A clearinghouse is the term used for the company who electronically submits the claim to the insurance company. A clearinghouse is a third party operator and may or may not be integrated into an EHR. Clearinghouses act as middlemen between the provider and the actual insurance company. If an EHR does not have a clearinghouse integrated into its system, you'll need to select one. Clearinghouses are HIPAA compliant. You may or may not have to pay fees to the clearinghouse per claim submitted, or as a monthly fee. Some clearinghouses are free, such as availity.com. I've been submitting claims through Availity for years with little problem.

The primary role of the clearinghouse is to adjudicate the claim by confirming that the claim meets the insurance company's rules of acceptability. For example, ensuring that the client is a covered member on the date of service, ICD code is billable, and that the counselor is on the panel.

One of the better solutions is to submit through an EHR, otherwise you have to duplicate information once into the EHR and again into the clearinghouse. When a counselor has an EHR, they will need to follow the directions for submitting claims from within the EHR.

All insurance claims must include a plethora of information. So are you ready to see this plethora of information? Can't wait, can you? So exciting, I know. OK, here's what's got to be included on claims.

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Claims are rejected for various reasons, including inaccurate numbers on the claim, client not insured for the date of service, coordination of benefits is necessary, claim was submitted to the wrong insurance. When the claim is accepted by the insurance company, payment is made on an explanation of benefits, or EOB. It's generated and sent to the client and to you.

An EOB is the explanation to the insured, as well as to you, explaining the amount paid by the insurance company. It includes the amount of any co-pay or co-insurance owed by the subscriber, as well as any write-offs between the insurance company and you. For electronic claims, it is more common for you to receive an ERA, or electronic remittance advice, instead of an EOB. Same deal, just in electronic form.

ERAs are important because they can be directly imported into the EHR. This means that you or your office staff do not have to manually import all of the accounting information about each payment. These are a huge time saver, because one ERA can include at information about several sessions as well as different clients. Thus multiple pieces of information can be integrated into each client's chart within the EHR with the click of a few buttons.

Here's what we covered in this lesson. First, timely filing, next, claim paperwork, clearinghouses, EHRs, and claims submissions.

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