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The medical insurance specialist should follow up with the insurer on the 15th day if there isn’t a response to the claim.
Some medical management software has an automated claims status request feature that tracks the claims status. It determines outstanding claims and then automatically sends an electronic inquiry to the insurer regarding the status of the claim.
Inquiries and responses about pending claims are made using the HIPAA Health Care Claim Status Inquiry/Response electronic transaction format that is available at most medical practices, healthcare facilities, and insurers.
An inquiry is referred to as a 276 message, and a response is a 277 message. A request message contains information that identifies the claim in question and the insurer’s response by using a response code. These are A Acknowledge. The insurer acknowledges receipt of the claim.
E Transmission error. The message was garbled and needs to be re-sent.
F Finalized. The claim is approved.
P Pending. The insurer is waiting for additional information.
R Request for more information. The insurer requests additional information about the claim.
The HIPAA Health Care Claim Status Inquiry/Response electronic transaction format is no substitute for personal contact with the claims examiner and other representatives from the insurer. Medical insurance specialists should develop a rapport with claims examiners who frequently handle their claims.
In doing so, the medical insurance specialist should be familiar with the insurer’s policies and schedule for processing claims. She should learn the particulars about each insurer’s claims adjudication process and the level of authority each member of the medical review team has to approve a claim. This gives you an idea who on the team needs to sign off on your claim.
Knowing the insurer’s adjudication process gives you the opportunity to learn shortcuts through its system that help to speed up reimbursements. For example, an insurer may have a telephony system that enables you to send missing or corrected claims information by pressing buttons on your telephone. A telephony system uses buttons on the telephone to interact with computer software (i.e., “press 1 for customer service, press 2 if you want to place an order”).
Medical coding Services omissions, identification on support documents, and intact claim form. Certain errors might cause the insurer to suspect fraud. These are undocumented procedures, double billing, unnecessary procedures, and itemizing fees.
An insurer has several options open to it when an error is uncovered. It can deny the claim, ask for a corrected claim, reimburse less than the claim amount, impose a financial penalty, or refuse to do business with the healthcare provide.
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