E Care Insurance Claim Form
Let`s visit them again now. Managed Care Organizations (CMOs) are groups, organizations or other institutions that seek to reduce the cost of health care and increase efficiency or health-related services through a variety of means. Most plans have some basic similarities. Most insurance plans require policyholders to pay premiums, which are essentially subscription fees. These can be allocated monthly or annually. Similarly, if we look at a patient covered by an HMO, but that patient sees a provider outside the network, we need to know that we cannot send a claim to that HMO, but rather we must bill the patient directly. (Keep in mind that HMO subscribers can`t get insurance coverage if they see providers outside their network.) Now that we have an idea of how some of the basic aspects of health insurance work, let`s take a look at the different types of health insurance. Now that you have an idea of what the billing process looks like, it`s time to take a closer look at the non-life and insurance part of this process. The process of settling accounts with an insurance company or other third-party payer is difficult to summarize because it depends largely on variables. These variables include elements such as the patient`s insurance plan, the payer`s guidelines for filing claims, and the provider`s contract with the payer.
Our goal in these courses is to prepare you for formal medical billing training and not to give you detailed details about the various technical details inherent in the claims process. However, in later videos, we`ll provide you with a number of work examples, and in subsequent courses, we`ll learn about two of the most important aspects of the medical billing profession and its relationship with third-party payers: Medicare and Medicaid, and HIPAA. Policyholders may also have a co-payment or co-insurance contract with their insurance company. A co-payment is a relatively small fixed amount that must be paid before a medical service is provided. The share will not be deducted from the deductible. At one time, HMOs were the most popular option for MCOs. HMOs work by offering subscribers a low premium and a strict network of providers that a subscriber can see. If a subscriber sees a provider outside of this network, they may need to cover all the costs of this service out of their own pocket. HMOs are often among the cheapest MCOs, but are also the least flexible. HMOs also often use family physicians (PCPs) who can act as “gatekeepers.” Subscribers often need to be referred to specialists by PCPs. Co-insurance is a type of agreement with the insurance company that divides the responsibility for payment into a percentage.
Co-insurance is quoted first with the share of the payer (the insurance company) and then with that of the subscriber. For example, if a subscriber receives a $300 medical procedure and has an $80 to $20 co-insurance agreement with their insurance company, the subscriber will owe 20% of the bill ($60). The insurance company would pay the rest. Let`s talk briefly about electronic and manual application forms. HIPAA regulations require that most claims transfers be made electronically. This does not mean that all claims are filed electronically, although this is probably ideal. Compensation is the simplest and simplest type of insurance because you pay a premium to an insurance company to protect you from medical expenses. You probably have a deductible and, depending on your insurance plan, a co-payment or co-insurance.
Compensation plan subscribers have no restrictions on the providers they can see, but compensation plans are generally much more expensive than managed care options, which we`ll look at now. Let`s say we charge a procedure that costs $1500. The patient who received the procedure has a CDHP with a deductible of $1000. To create an accurate claim, we would review the patient`s coverage plan and award the $1,000 deductible to the patient, and then pass the $500 back to the payer. For example, managed care organizations may limit the providers that the subscriber can consult to a specific network of physicians and institutions. In general, MCOs have lower fixed costs than most compensation plans, but limit a patient`s options as to where they can be treated. There are three main types of MCOs, which we will discuss below. Keep in mind that these are simplified descriptions of these managed care organizations. The two most common claim forms are the CMS-1500 and the UB-04. These two forms look and work similarly, but they are not interchangeable. The UB-04 is based on the CMS-1500, but is actually a variant of it – it`s also known as the CMS-1450 form. .
