Before you send your claims, make sure:

 

1)  The patient demographics are entered exactly as their insurance has them entered;

 

2)  the patient's insurance information is entered exactly as the insurance card shows (also send the claim to the address on the card);

 

3)  don't try to overbill.  An office visit usually covers most issues (unless an additional procedure was done).  Make sure to bill what the physician did;

 

4)  the rendering doctor and referring physician each need their own NPIs shown in the appropriate spots on the claim;

 

5)  if this is a Workers' Comp claim, you will need the WC ID# (instead of insurance ID) and a DOI; and,

 

6)  the appropriate amount is 120% of what the Official Medicare Fee Schedule shows.  More than that will most likely have to be written off.

 

 

When you have received an EOB for a claim:

 

1)  If you received, "Member not known," this usually means that the subscriber information is not correct.  Look at the Insurance Card, and make sure Subscriber / patient (member) information agrees with what was input on the claim (also make sure the address info agrees with what the Insurance agency has on their file);

 

2)  If you received, "Physician NPI not found," make sure physician's NPI was entered correctly;

 

3)  If the paid amount from the Insurance Agency was the Medicare allowed amount, and there is still an unpaid balance - you will either have to balance-bill the patient (non-Medicare), or write off that amount;

 

 

NOTE:  Workers' Compensation Physicians ... did you know that the Department of Industrial Relations authorizes you to charge $250/hour for the time you spend writing Workers' Compensation patient reports ?  Call (818) 227-5027 to find out more details.