Reduce Your Medical Billing Firm's Claims Rejection Rate!

IMPORTANT TO KNOW... Stay on top of current and changing requirements to reduce your Medical Billing Firm's claims rejection rate!

Treatment may be covered for one condition but not covered for another. For example, arthodesis may be covered for a dislocation but not covered for an anomaly. Remember, the pairing of the condition with the treatment determines which line the service is on.

Reasons For Denied or Returned Claims:

A Clean Claim means a claim that has no defect, impropriety, lack of any required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment in accordance with the Member's Health Benefits Plan and the Provider - Payer Agreement.

A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant, or Peer Review for medical necessity.

A clean claim shall accurately reflect billed Charges. “Substantiating Documentation” includes, but is not limited to:

Legible claim form—CMS UB 92, CMS 1500 or other required forms
Full Name of Patient/OHP Member
Member's Date of Birth
Member's Recipient ID Number
Date(s) of Service
Place of Service
CPT Procedure Code
Modifier(s) if applicable
Line Item and Total Charges
Quantity of Units of Service
ICD-9 CM Diagnosis Code (to the highest specificity)
Physician's Name and Address
Physician's Tax ID Number
Bill type
Admission date and time
Discharge date and time
Billing number for Facility
Revenue Center Code
Date of Service for each line item
Quantity of units of service
Line item charges
ICD-9 CM Diagnosis Code (to the highest specificity)
CPT HCPC code
Attending Provider Number
If applicable, Inpatient Nursing Facilities
Bill type
Admission date and time
Discharge date and time
Nursing Facility Billing Provider Number
Type of Admission Code
Patient Discharge Status Code
Date of Service (dates of admission through discharge)
Dates of Service through discharge except continuous stay nursing facility clients
(Use the last day of the month or the discharge date)
Revenue Center Code(s)
Line item charge(s)
Total Charge
ICD-9 CM Diagnosis Code (to the highest specificity)
ICD 9 CM Procedure Code when a procedure is performed
Attending Physician OMAP Provider Number
Written referral, if applicable

A Clean Claim shall not include those claims which require coordination of benefits and third party liability issues until receipt of Explanation of Benefits from primary carrier or claims, which are being reviewed by the Medical Director, Medical Consultant, or Peer Review for medical necessity.

Do yourself a favor and cross-check each claim that you enter to verify you have all applicalble information above.
You are a professional medical biller - do your BEST to gain the knowledge and skills required to EARN the right to call yourself such.
For help or guidance on this and more, visit www.MedicalBillingFoundation.com