WC
What information do we verify with the adjuster when we call prior to the patient's appointment?
We verify the claim is open and active, claim #, claim address, DOI, phone/fax, and that we have the correct adjuster as well as if there is a nurse case manager and for what body part, and if they are willing to authorize any visits (eval +), we also want to know who the authorization goes through and how to contact them.
What is an SB811?
SB811 is a letter to inform the patient that they are Self-Pay and that an estimate is being provided for services.
The "SB811" is for patients with no insurance while the "SB811 OON" is for patients who are out of network or may want an estimate who have insurance but a high deductible and may be financially responsible for their cost of care
If a patient has no medical coverage on their MV insurance and give us a declaration page or no Med-Pay letter, can we bill their health insurance?
Yes! This is the only time we can bill their personal health insurance if they have been involved in an MVA
For a date extension how would we set up the referral?
set the counters in the authorization tab to 550 both the requested and authorized override. Set the referral to Pending / Not Enough Information
what do you say when you answer the phone in the clinic?
Good (Morning/Afternoon), ___Hospital Name__, this is __YourName__, How can I help you?
What form do we need from an adjuster to bill through a patient's health insurance?
If a patient is denied though WC, we need a Form 43 from the adjuster to send to the health insurance with the clinical notes when submitting for authorization to show the patient was denied.
If the patient has health insurance and decides to be Self-Pay are they eligible to receive the discount?
No, We need to remove the Self-Pay discount if the patient has insurance, but chose not to utilize it.
What is Med-Pay?
Med-Pay is an additional coverage option for auto insurance policies in most states. In the event of a car accident, this coverage can help pay for medical expenses for the policy holder
if a referral is closed or closing due to the end date and we need re-auth or a date extension what would we do?
set the referral to Pending / Not Enough Information and set the End Date in the Authorization Tab out 2 weeks only allowing the referral to stay open to obtain the re-auth or date extension. Make notes in the communication tab notes that this was done.
When should we have a patient fill out a functional tool to score on file? (Quick Dash, LEFS, NDI, MDQ, PFIQ, LLIS etc)
Limber should send this out to the patient when it is time. It should be done for the Eval and again for PN and the front desk can manually push them out through Limber. Make sure to keep track of compliance on the DAR through the PRO column.
If a patient is WC and does not have their claim information can we bill their health insurance?
NO! patient is responsible to get us the WC information or a person at their company who can provide the information. they are marked self-pay until they can obtain that information. They will receive estimates for each visit.
What documents need to be signed and scanned for Self-Pay at each visit?
SB811 Letter (at eval) and the estimate with charges(each visit).
Always best to have a signature on the page where the charges are and a signature on the letter then they all need to be scanned into MM
Unless the estimate was sent to the patient in MyChart 24 hours prior to the appointment by finalizing the system generated estimate.
What information do we need for a patient with medical coverage on their motor vehicle insurance?
MV insurance Carrier for the patient
Claims address
Date of Injury
Claim Number (Not policy number)
Adjuster's name
phone and fax for the adjuster
then the PSR needs to call and verify the claim is open and active and for what body part(s), who the authorization goes through - Adjuster, NCM, 3rd party and verify the med-pay amount and possible amount remaining
If a patient is seen for their last visit and needs a re-auth what do we set the counters in the Authorization Tab to?
500 - but only after the patient has been checked in for their last approved visit or it is the last visit the patient will be seen prior to the end date running out and date extension is not available. The therapist needs to do a PN at this visit in order for the CPSR or PSR to submit for more visits.
Do we need a Carelon Form to be filled out by the therapist and scanned in for re-auths as well as for evals?
YES! There is a section on there for initial evaluations and a separate section for re-auths that help the Central team facilitate getting those visits authorized from Carelon. If this is not filled in and scanned into the chart, the answers are not always available to us when obtaining auth. This needs to be done the day of the Eval or re-auth being needed
What happens if a patient is denied by WC?
The site will receive notification from the auth specialist in regards to the denial. The site would communicate to the patient they were denied coverage through workers compensation and to reach out to their adjustor or employer. If the patient wants to continue, they will sign a self-pay waiver or provide personal insurance for medical expenses.
How do we remove the Self-Pay discount from an estimate?
You can do it 2 ways:
You can click the discounted total in the "TOTAL" section after adding in all CPT codes and the discount percentage box pops up to the left of the box, you can put 0 in the box and hit enter
Or you can 0 out the discount box with each CPT code you add.
If a patient has not opened a claim with their MV insurance and has medical coverage and wants to bill through their health insurance, can we? Why?
NO, If the patient has medical coverage we need to exhaust that prior to billing their health insurance or the health insurance can deny the claim stating to bill the MV policy
What information needs to be in the referral for the benefits collection?
Effective date
Calendar / Plan year (plan year dates)
are we in network (does patient have OON benefits)
Copay
Deductible - Amount met
OOP - Amount met
Does the deductible contribute to the OOP
Coinsurance
Visit Limit - Visits Used (even if the patient has visits based on medical necessity)
Hard or Soft Max and how we submit if it is a Soft max
is Auth required through whom and how do we submit
is there a visit limit allowed before auth is required
is an electronic referral required by the PCP and how is this submitted
Reps name or web site
call reference # or transaction number
and if the benefits were obtained through the website upload them into MM
what form do we need for UHC MGD patients for evals and re-auths?
The Patient Summary Form
PSR fills in the top portion
Therapist filled in the middle portion
Patient must fill in the bottom portion of the form
What information do we need from the patient for a WC claim?
WC insurance Carrier
Claims Address
DOI
Claim Number
Adjuster's Name, Phone and Fax
Employer, Phone and Address
If the patient is marked for Self-Pay because of MVA or WC are they eligible for the discount?
No! The patient is not eligible for the self-pay discount as a MVA or WC patient. We need to remove the Self-Pay discount from the estimate.
If a patient is in the back seat as a passenger in a car and is hurt in an MVA can we bill their health insurance? Why?
NO! We need a Med-Pay or declaration page from their personal car insurance letting us know they have no medical coverage to bill their health insurance. If they have no insurance they would be a self-pay and would have to submit their bills to the person at fault to pay. It does not matter where in the car the patient was (driver/passenger) including if the patient is a pedestrian the Med-Pay must be through their own vehicle's insurance
How do we transcribe an order?
Transcribe order from toolbar
add the provider
"add order" AMB ___(Therapy (PT/OT)/Speech/Lymphedema)
choose department
initial evaluation/neuro condition
add in the DX association (add dx, check box and accept)
sign order
What is an insurance referral or PCP referral?
An insurance referral is to be submitted to the patient's insurance directly by the PCP they have on file with their plan for approval of therapy services, even if they are not the provider referring them to therapy. Once approved by their insurance plan, the insurance referral will include a number of approved visits, a date range to use the approved visits, and an approval number which will be submitted on the claim for services rendered to the insurance plan.
It is the patient's responsibility to ensure this approval is in place prior to services being rendered to avoid denials.