EDI Claims Submission for Out-of-Network Claims

One of the most critical functions in a provider’s office is insurance claims submission. ActivHealthCare (AHC) understands the importance of this task. With EDI, you may file your out-of-network claims electronically in addition to your in-network claims.

The steps for claims processing are as follows:

Step 1      Verify patient’s insurance coverage through insurance payor. Be sure to verify that you are listed in the PPO network, if applicable.

Step 2      Determine if the patient's insurance is listed in the network affiliates or employer lists. If this is an in-network claim, view the instructions for filing AHC in-network claims or I-AHC in-network claims.

Step 3 Thoroughly complete the health insurance claim form in your management software program. This form is often referred to as a CMS-1500. Be sure to pay attention to the requested information. The following boxes are often completed incorrectly on the CMS-1500:
1a.     Insured’s ID Number
4. Insured’s Name
8. Full-Time Student (if appropriate & child is 18 or over)
9a-d. Other insurance information (if applicable)
10a-c. Patient’s Condition Related To: (extremely important)
11. Insured’s Policy Group or FECA # (see ID card)
11a. Insured’s date of birth & sex
11b. Employer Name (see ID card)
11c. Insurance Plan Name (list PPO network name) (Obtain from the ID card)
14. Date of Current Illness or Injury
31. Provider’s name
32. Name & Address of Facility (put office address here)
33. Physician’s Suppliers Billing Name. A pin number is required here. If the payor requires a pin, use their assigned pin number. Otherwise, use the doctor’s license number.
The list above in not comprehensive, but these are the fields that are often left blank or completed incorrectly. Please be sure to become familiar with the form and the process your office follows for completing it. If the form is not completed it will either slow down the claims process or result in the claim being denied by the insurance payor.

Step 4 Obtain the insurance payor’s information from the insurance identification card. The upper right hand corner (above box 1a.) of the CMS-1500 form has a blank space. The name and address of the insurance payer should go in this space in the following format (see Example 4):
  Insurance Payor’s Name
  Insurance Payor’s Street Address or P.O. Box
  Insurance Payor’s City, State & Zip Code.

Step 5 The claim is then uploaded to Office Ally. If the claim form is completed properly, your claim will be forwarded to the appropriate insurance payor within 24 hours after receiving the claim.

Step 6 The insurance payer will send your explantation of benefits and payment to your office.