Different Types of Medical Insurance Claims

People think of medical billing and they think there is just one type called medical claims. But there are different types of medical claims and different types of insurance plans and sometimes they have to be submitted in different ways on different forms. Knowing which type of claim is being billed and knowing which type of form to bill it on are key to getting claims paid and maintaining a consistent cash flow.

Regular commercial medical insurance is the most common claims you will come across in medical billing and they are billed on CMS 1500 forms or electronically thru a clearing house. Most plans are employer sponsored and patients have them from either their job or their spouse’s job. They can be indemnity plans, HMO’s, PPO’s, EPO’s or group health plans.

Medicare is government sponsored insurance for the elderly or disabled. In most instances Medicare claims including when Medicare is the secondary policy must be submitted electronically. Small practices can obtain a waiver. Patients with Medicare have the option to enroll in a Medicare Advantage Plan at no additional cost. It is very common to receive denials from Medicare stating the patient has a Medicare Advantage plan.

Medicare Advantage Plans are the plans that patients can opt to have in place of their Medicare. Usually patients have a copay for most services instead of co-insurance and a deductible. Patients with an Advantage plan would not usually have any secondary insurance. You can sometimes get info from Medicare regarding which plan a patient has if denied for other insurance. Medicare advantage plans can be submitted on CMS 1500 forms or electronically. Most Medicare advantage plan carriers accept electronic submissions.

Medicaid is a state sponsored plan for low or no income people. Since it is a state sponsored program the laws vary from state to state. It is important that you know and understand the laws for any state you are billing in. Many states allow their Medicaid claims to be filed on CMS 1500 forms. Some states, like NY have special forms that they require. Many states do accept electronic claims. Some even have the ability to submit claims online thru their website.

Auto accident claims or No Fault claims are claims for services relating to an automobile accident. They are filed on CMS 1500 forms to the auto insurance carrier – not the medical carrier. Some no fault carriers do accept electronic claims but most don’t. And it’s not uncommon to have to attach something like notes, or a statement authorizing benefit payment to be made to the provider. There is a place on the CMS 1500 form, box 10 where you indicate if it was related to an auto accident and the state that the accident occurred in.

Worker’s Comp claims are claims for services relating to an accident at work. The rules of billing workers comp vary from state to state. You really need to check the regulations in the state you are billing. Many states including New York require use of a special form when billing worker’s comp services. It can usually be printed out from the worker’s comp website. Copies of all claims must be sent to worker’s comp board as well as the worker’s comp carrier. Rules for worker’s comp in NY changed drastically on December 1, 2010. Prior to that a provider just submitted claims with the allowed codes. The codes had been the same for over 20 years. For example, a chiropractor was only allowed to bill a 99203 for the first visit and a 99213 for any visits after the first. It didn’t matter what services the dr did, they could only bill those codes. Most comps didn’t require any kind of authorization and the patient could come as long as they wanted to. Occasionally the comp carrier would request an IME (independent medical examination) and then cut the patient off. But most patients received treatment for years. Under the new rules the providers must bill different codes and the patients can only receive treatment for a short period of time. Then the provider must request a variance for ongoing treatment. The variances are requested by submitting a form that also can be obtained on the web site. It is now much harder for a provider to treat a comp patient for much longer than a three month period.

Personal Injury claims are claims for services that are the result of some sort of a personal injury such as a slip and fall at a grocery store. For example, the other day my father-in-law fell outside of a Big Lots. He tripped on the curb right in front of the door, fell and cut his head open and the store manager called an ambulance. They took him to the hospital for stitches. (Thankfully he was ok except for that gash above his eye.) My brother-in-law and I arrived at the store after the ambulance had left. The store manager handed us a paper with all of their insurance information on it, including the address for us to submit claims. These claims are submitted on CMS 1500 forms to the insurance carrier for the responsible party. They are billed the same as you would bill to a regular insurance carrier, you just mail them to the personal insurance carrier for the responsible party. Same codes, regular fees.

Facility claims
are claims for services rendered at a provider that is classified as a facility such as a hospital, drug and alcohol rehab, eating disorder clinics ambulatory surgery center. Claims for facilities are usually filed on UB04 forms with Rev codes instead of CPT codes. The forms are quite different from the CMS forms but they really aren’t that bad. The biggest issue is that most practice management systems don’t print them so you need separate software. There is a UB04 form filler software available for about $250 that is really a pretty good software. And our book on completing the UB04 is very comprehensive. Providers that require billing on the UB04 can make great clients. We go into greater detail on Facility Billing in that section.

There are many different types of claims. Even though most are submitted on the CMS 1500 form (or electronically) it’s important to know the different ones and understand the differences.


4 Responses to “Different Types of Medical Insurance Claims”

  1. Claudia Says:

    I’m not quite sure if some of your comments on worker’s comp claims were referring to only New York or not. But just to clear up one point, here in California, we don’t send claims to the worker’s comp board, only to the insurance carrier. It appears that New York followed California’s lead with worker’s comp reform. We went through all that in 2004 and believe me, it was very hard for my chiropractic clients to adjust from being able to treat patients without limitations to having to justify why they are treating them. Paperwork is never the strong suit of providers!

  2. Michelle Says:

    You guys are the best and sooooooo smart , as a young independent speciality biller for home health , I love reading your articles!!!!!

  3. barbgris Says:

    Nice overview! But don’t forget Employee Assistance (EAP) programs, which in my experience rarely can be billed on CMS-1500 forms, and often need to be billed on the EAP’s own billing form — and which may also require some sort of treatment summary to be filled out and submitted with the bill.

    Barbara Griswold, MFT
    Author, Navigating the Insurance Maze: The Therapist’s Complete Guide
    to Working With Insurance– and Whether You Should

    • Claudia Says:

      Having billed for a few mental health practitioners, I wish I would have known how EAP works instead of doing the trial and error method! I finally figured it out (after much frustration and not much help from the prationers!) and usually my clients fill out the ones that have their own forms. There are a few, however, that will accept the CMS forms.

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