Whose Primary
The patient has health coverage through a spouse’s retiree plan. The spouse is not actively working.
Question:
Will Medicare be primary?
Yes – Medicare primary / Retiree plan secondary
The claim was submitted to the insurance; insurance denied the claim, advising the balance is patient's deductible. However, the patient is advising deductible was met.
First support review, this should be sent back advising that updated EOB is needed.
Secondary review sent to the follow-up team for confirmation of balance.
The patient was seen at the Urgent care and is wanting us to send the claim to VA without an Auth. Can we bill to VA?
Will Medicare Part A cover a patients provider bill from their emergency room visit?
No, Medicare Part A will not cover emergency room visits nor provider bills because they are considered out patient services. Medicare Part A only covers inpatient facility visits.
What is an area in Epic where you can go to confirm if a claim has been sent to the insurance?
Will accept multiple answers
The patient is 66 years old, actively working, and covered under their own employer-sponsored plan with more than 20 employees.
Question:
Will Medicare be primary?
No – Employer plan primary / Medicare secondary
The Medicare member claim denied due to COB. Upon review COB has been updated. Does this go to follow up team for review?
No need for follow up. The support rep should bill this charge to Medicare due to COB update.
The patient is a newborn baby and mom has called in advising we need to bill the VA. Are we able to send the claim to TriWest?
Yes, we can bill TriWest for an infant within 7 days of life.
A newborn baby services were billed, and processed by the patient's mother insurance. Mom is now wanting us to bill the 3-month check-up; however, the baby has not been added to the policy. Can we bill the 3-month check-up visit?
No, the baby is covered under Mom's insurance for the first 30 days of life. If the baby has not been added to the policy the baby will not have active coverage and no claim can be billed.
I am working a PB account, and I have to NRP the charges. I accidentally hit "yes, no claim" however I noticed the balance went to the insurance bucket. Has this been billed?
No, "yes, no claim" will move the money to the insurance bucket and prompt the account for follow up review. This is not you sending an actual claim. You must select "Yes" in order for claim to generate.
The patient has Medicare insurance due to a disability (patient is under age 65).
The patient is covered under a working spouse’s employer-sponsored commercial plan.
Question:
Will Medicare be primary?
No – Commercial primary / Medicare secondary
The patient advised they have BCBS we previously billed ID:ABC1234567 and received a denial stating benefits termed however, the patient is now providing id:DEF2345678, and you were able to verify the coverage was active at the time of service.
No, you can add the new policy remove the prior and submit a primary/new claim to the insurance.
The patient was seen for right knee pain and is requesting we bill TriWest. We currently have an older authorization on file for the patient's lower back. Can we bill TriWest with this Auth?
No, the authorization needs to reflect the diagnosis related to the services rendered during the patient’s visit.
Can I submit a claim for STI testing if the patient only has Medicaid Family planning?
Yes, family planning Medicaid will cover STI testing.
The support rep prior worked the account and noted insurance was billed. However, you noticed there was a claim error, and you are not showing a claim issued date. Was it billed?
No, Epic will generate a claim the following day and place the claim date in the insurance bucket. Also a claim error will automatically stop a claim from going out and will need to be corrected to complete billing.
The patient has COBRA coverage from a former employer.
Question:
Will Medicare be primary?
Yes – Medicare primary / COBRA secondary
The patient has called multiple times to have their UHC billed. However, the coverage was already billed and denied due to CO-24 capitation agreement.
Yes, the account should be sent to the follow-up team for review of patient responsibility. Typically, this code is a contractual obligation, and the patient should not be billed.
The patient authorization on file is not verifying in the TriWest portal. However you noticed in the notes the VA rep has called to advise to bill them directly. Can we bill TriWest?
Yes, the VA calling is verification and you are able to submit the claim.
The patient has turned 65 and is now on Medicare. She was seen for her yearly exam. The account was coded as Initial Annual Wellness Visit. However she is receiving a bill because Medicare denied her claim. What could have taken place?
Mostly due to the patient turning 65 this is their very first visit with Medicare Part B. Instead of the account being coded as an initial annual visit, it should be coded as a welcome to Medicare visit.
After billing you noticed the balance is sitting in the self pay bucket. Has this been billed?
No. In order for a claim to be submitted the balance must move to the insurance bucket for billing.
The patient is 67 years old and has coverage under a spouse who is actively working and enrolled in an employer-sponsored commercial plan.
Question:
Will Medicare be primary?
No – Commercial primary / Medicare secondary
The patient advised they were seen for a preventive visit. However, they are receiving a copay and want the claim rebilled.
No. This example would need to go into dispute AA (785) for a coding review. Please place detailed notes to advise the client all the places you looked to validate the code.
The patient called noticing they are being billed for an ambulance ride, and the patient is wanting us to send the claim to TriWest. Can we bill TriWest?
Yes, VA can be billed. TriWest will make the determination if it is covered services or not.
The patient has a billable service under their "Self pay Package" guarantor and they are requesting that we submit the claim to their insurance. How do we submit the claim?
The account should be worked under the patients PF (Personal Family) Guarantor, once this is done, if billing doesn't happen automatically, please follow traditional billing steps.
I am billing secondary insurance on an HB account. I undo the billing "1 time" and the balance is moved to the primary insurance in the insurance bucket. Did I bill the patients secondary insurance?
No, the balance will just continue to sit in that bucket until you add the secondary coverage and NRP (Next Responsible Party). From there, you should see the balance moving to the secondary insurance.