Claim Submission Checklist

Claim Submission Checklist

The following claim submission checklist will help providers or billers to ensure all necessary (and accurate) information are provided at the time of claim submission.

Facility Setup Checklist

1. Verify the following information for each insurance payor:

  • Payor ID
  • Confirm the NPI and Tax ID/SSN that each provider bills under for each payor
  • Claim Filling Indicator Code
  • EDI or paper claim submission

 

2. Complete Electronic Data Interchange (EDI) enrollment:    

  • Sign up for EDI enrollment for each payor 
  • Track payor approvals as they're received

 

3. Complete ERA Enrollment for each payor:  

  • Sign and return any required payer agreements
  • Track payer approvals as they're received

 

4. Verify the Facility Information:

  • Name, Billing Address, Zip-Code, and Phone Number
  • Group NPI and EIN
  • State License Number
  • Provider Taxonomy
  • Billing Facility Name and Address with Zip Code

 

5. Verify the Provider information and claim settings:

  • Full Name and Address with Zip Code
  • Individual NPI
  • Provider Tax ID
  • Billing Provider Entity Type - Individual or Organization

 

Diagnosis & CPT Codes Checklist

When selecting a level of service one must:

  • Identify the category or subcategory of service provided
  • Review the instructions for the selected category or subcategory
  • Determine the extent of examination performed
  • Select the appropriate level of E&M service based on CPT® definitions and criteria
  • Make sure the order of diagnosis and CPT codes are correct
  • Do ensure the initial treatment date and other dates are entered correctly
  • Make sure to Recalculate and Save every time you make changes to an invoice

 

Patient Details Checklist

1. Verify patient information before creating an invoice or claim:

  • Verify the patient's name, date of birth, gender, and address against the patient's ID
  • Verify the patient's primary/secondary/tertiary policy information against the insurance card
  • Verify insurance plan name, Group ID, and Member ID
  • Make sure the insured person's details are filled in the profile
  • Make sure the insurance to be billed is active 

 

2. Verify the following information for each insurance for a patient:

  • Active insurance details
  • Patient copay (if applicable)
  • Prior Authorization Number (if required) 
  • Box 17 - Referring Provider or Other Source (if required)

 

First Claim Submission Checklist

1. Verify you have enrolled for ERA and EDI for each payor

2.  Verify the payor details are correct and up to date

3. Verify the insurance details are filled correctly in the Patient Profile

4. Verify the Patient Demographics are correct and up to date

5. Send one claim to a payor first. When acknowledged successfully, start sending multiple claims from the next time.





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