Sending Claims to Insurance

There are two ways to send medical claims to the insurance company, electronic and paper. The paper method is outdated. Very few paper claims are being processed anymore in the electronic age. However, if you have to send a paper form, sending them  is fairly simple…mail it. Still, there are problems with paper claims that make conversion to electronic claims very worthwhile. Sending a paper claim is more expensive than an electronic claim. Many do not consider the costs in their entirety. Remember that the mailing costs more than the stamp, the cost of the claim form, printer toner, the cost of the envelope and the cost of a biller’s time to prepare the claims. Unfortunately paper claims won’t go away just yet as they are still required by some smaller insurance carriers, for appeals and some corrected claims, But, try to avoid them when/if possible.

An important part of sending a paper claim is the address to which you mail it. Incorrect mailing addresses it the number one reason that claims are “not received”. Most patients’ insurance cards have a claims mailing address on the card, but just because it is there doesn’t make it right. The card may be old or the insurance changed office locations and the patient has not yet received the new insurance card. After a while you will become familiar with your practices most common insurances and their mailing address. But here are a few hints about sending paper claims to the right place.

·                       Pay close attention to the mailings, updates and letters that your insurances send to you. Most insurances will announce a change in their mailing address in advance with an effective date.

·                       Understand Medicare’s claims submission rules. Medicare and Medicaid are government programs (governed by CMS). The programs hire other agencies to process claims for them, these other agencies are called fiscal intermediaries. The contracts for a fiscal intermediary are awarded and change from time to time. With the change of fiscal intermediary the claims mailing address will also change. Watch your Medicare updates carefully. Remember, too, Medicare and Medicaid HATE paper claims and have limitations regarding who can send them. So before you bill Medicare/Medicaid on paper check to see if you are eligible.   

·                       Medicare requires that claims be sent to the Medicare fiscal intermediary responsible for the location where the services were preformed. For example, your practice has two locations one in New Jersey and one in Pennsylvania. On January 1 the patient John Doe was seen in the New Jersey office - send the claim to New Jersey Medicare because the doctor treated the patient in New Jersey. On January 2 the patient John Doe was seen in the practices Pennsylvania office – send the claim to Pennsylvania Medicare because the patient was seen in Pennsylvania. The place where the patient lives or which is the doctors “primary” office has no bearing whatsoever on claims to Medicare only where the patient was seen. A final example on this point, the patient John Doe lives in Florida and is visiting New Jersey for the week, he sees a New Jersey doctor for a head cold. The doctor will send the claim to New Jersey Medicare.

·                       Understand Blue Cross Blue Shield claim submission rules. Blue Cross has a program called the “Blue Card Program”. This entitles eligible patients claims to be submitted to the “local” Blue cross Blue Shield. The local Blue Cross is the doctor’s local Blue Cross. Blue Cross Blue Shield has offices in every state in the union your local is the state or local Blue Cross for the location where the services were rendered. The insurance card will indicate the words “Send to your local Blue Cross blue Shield Carrier” and usually have a blue suit case on the card. The local Blue Cross address is usually not the same as the in-state claims addresses although electronically they usually are the same, so call Blue Cross and ask for the Blue Card address and phone number. For example, a patient is covered under Blue Cross Blue Shield of Maine and is seen by a New York doctor, the doctor will send the claim to the Blue Card address assigned to New York Blue Cross providers.

·                       Blue Cross Blue Shield very often divides their claims by policy type and different policy types have different addresses. For example, HMO claims go to a different address than PPO claims. Pay attention to the address on the card!!!!!!!

·                       Understand an “administrator”. An administrator is a company the processes some claims for special groups within an insurance network these claims often go a different address that regular claims. A good example is Amerihealth, as of now Amerihealth PPO and HMO claims are sent to one address. There is a division of Amerihealth called Amerihealth Administrators who processes claims for small groups and unions. Amerihealth administrators, although a division of Amerihealth is a different insurance company as far as claim submission and phone calls go.  If you see the word Administrator on the insurance card, pay close attention to the mailing address and don’t assume that it is the same as the regular insurance that you are familiar with.

·                       Confirm claim submission addresses while you are checking patient’s eligibility. This small step can alleviate a lot of problems and really takes very little time.

·                       When in doubt - CALL and ask the insurance. Have the patient’s policy number and the provider tax ID or provider number ready and ask where they want claims to be sent.

Many of these same rules will also apply to electronic claims. Even though there is no envelope and no paper claim, the address to which you send the claim is VERY important. The electronic address is called a payer ID and will be discussed in length in  the next post.