Assignment 3 Week 6: Procedure Posting Routines

Procedure Posting Routines

1. Name the three steps involved in the claims management process.

-Claims preparation

-Claim editing

– Claims submissions

2. Provide examples where paper claims might be necessary over electronic claims submissions.

It is important for the secondary billing in a situation that the explanation of benefits follow the claim or even an appeal form from the insurance for purposes of attachment.

3. There are some items insurance companies require to process medical billing claims. List at least eight (8) of these items.

-Name of the patient, SSN, age -Name of the person that rendered services -Identification number and the name of the referring physician (Walsh et al., 2013). -Information about health insurance plans -The date that the service was provided-service location-Proper ICD and CPT 10 codes-Policy holder’s insured’s address and name

4. Describe the NPI number, implementation advantages of it NPI number, and what type of provider must use the NPI.

The NPI is considered as the government issue identification number for specific healthcare organizations like hospitals, clinics and schools and their healthcare providers (Kennedy et al., 2014). This number has brought a new level of standardization through the use of electronic transactions and have improved the acceptance rates. The NPI numbers are only to be used by the health organizations and the healthcare providers.

5. Describe two specific factors that greatly reduce denied claims and limits the amount of insurance follow-up and tracing to be done.

These are the services and data rendered are required to be accurate and also need to have a proper reflection on the claim.

6. Describe some ways reimbursement may be affected by a patient who receives services from an out-of-network provider.

Reimbursement is considered as giving back something for an expense (Gelber,2001). A person that is being repaid for an out-pocket expense when the person receives the expenses for reasons of carrying out the duty or through employment for another party member.

7. Give examples of times when Medicare is the secondary payer (MSP).

In the case that a patient is 65 years and above and has an LHHP cover because they are employed currently then Medicare is the secondary payer (Green,2016). If one has no liability or faulty insurance, then Medicare is the secondary payer.

8. A patient with Medicare is working at a small business with fewer than 20 employees. She has a group plan with this employer.  Which insurance is primary for services?  Explain your answer.

Medicare is the primary for services because the business she works for is small and has less than 100 employees while Medicare requires a minimum of 100 employees to become a secondary payer.

 

 

References

Gelber, A. (2001). U.S. Patent Application No. 09/972,129.

Green, M. A. (2016). Understanding health insurance: A guide to billing and reimbursement. Nelson Education.

Kennedy, B., & Bartlett, R. (2014). U.S. Patent No. 8,788,293. Washington, DC: U.S. Patent and Trademark Office.

Walsh, C. S., & Crowder Jr, R. J. (2003). U.S. Patent No. 6,655,583. Washington, DC: U.S. Patent and Trademark Office.