General
Patient account note information
Caller's name & relationship
DOS
Reason of the call
Actions taken
What do we need from the insurance to resubmit a claim that was previously denied by them?
Reference number // Agent's name (Medicare)
Difference between Medicare and Medicaid
Medicare: FEDERAL health insurance for people 65 or older and some people under 65 with certain disabilities or conditions.
Medicaid: STATE program that helps cover medical costs for some people with limited income and resources.
What is an Amendment form and when can we use it?
Amendment form: Is a form used to request the update of the pt's medical records from a visit.
We use it when we need to send a claim to the pt's private insurance, and the claim is a WC//NF.
Parts of HIPAA authentication
NAME
DOB
ADDRESS/PHONE NUMBER
Which is the only email you don't need to copy your supervisor and your QA.
Please Mail
Process we use to send the claim for the first time to the insurance, and we have to void all transferIN and move the pt's payments?
MGRHOLD
Difference between WC and NF
WC: Is used when the claim is a work-related injury
NF: Is used when the claim is a motor vehicle accident
How do we send an IB?
Encrypted
Only to the pt's email
BCC to supervisor and QA
A patient is considered to be of legal age as of
18
Where can I find the process to confirm a Medicaid eligibility?
Basics
Types of denials from the insurance
Coordination of Benefits
Incorrect Member ID
Demographics information (DOB, name, gender)
Lapse in coverage
Unactive on DOS
Which is the insurance we do NOT take as a primary?
Medicaid
What is a clinical complaint and who can place it?
When a patient calls to advise that the doctor has bad bedside manners, given a misdiagnosis, wrong medication, reaction to the medication, or anything related to what occurred with the doctor.
If someone other than the patient placed the clinical complaint with permission from the patient of course, we need to know that person’s name, relationship to patient and phone#
Where can I find a HIPAA form and how long does it last?
Clinicals, chart.
The HIPAA form lasts for 1 year.
How do we send a paper statement or any document by mail to the pt?
Sending the information by email to Please Mail
Where can I find any denial or note from the insurance regarding a claim?
Claim notes of the DOS
Information we need to add a WC/NF insurance
Ins name
Claim number & address
Adjuster's information
DOI
SOI
Injured body part
What is a first aid?
The claim is workers’ comp related but the employer is looking to pay out of pocket and not use the worker’s comp insurance.
Do we send claims to Medicaid?
NO
How you should send an itemized bill?
PDF format
Encrypted
BCC to supervisor and QA
Do we submit claims to Medicaid?
No
Difference between DROP and MGRHOLD
Drop: Used to send a claim from SUMMIT to the ins
MGRHOLD: Used to send a claim from an URGENT CARE VISIT
Name of the Holy Trinity of our docs
Urgent Care Handbook
Athena SOP
Basics
Can we submit twice a Coding Review? And explain why
No; we can submit twice a coding review, in this case if the pt is not happy with the resolution we can submit the claim to channel to have further instructions.