A properly completed claim (whether paper or electronic) is a critical component of the reimbursement process. A clean claim is vital to the processing and payment of your claims. The "cleaner" the claim, the faster you will receive payment. It is the responsibility of the provider to understand what is needed and required by the carrier, then provide that information in the specified manner and time frame.
You need to understand the following concepts:
- Claim Followup Procedures
- Denial Management
- Appeals Process
See also Chapter 1-Insurance and Reimbursement in the Behavioral Health DeskBook for important claims processing information..
- CMS Timely Filing Instructions
- Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (resource 352)
- UB-04 - Medicare Claims Processing Manual Chapter 25 CMS-1450 Data Set (resource 410)
- 1500 Claim Form - Medicare Claims Processing Manual Chapter 26
- GAO Report on private payer claim denials and appeals (resource 202)
- New AMA Study: Patients Responsible for Nearly One-quarter of the Medical Bill
- Grandfathered health insurance plans by Healthcare.gov
- Voluntary Refund Form
- Prompt Pay Letter