Claims submission to insurance
- As most insurance payers allow for (EDI) electronic claims submission the process has become easier. Versus in the past, some claims had to be mailed or faxed to the insurance. The uniformity of the EDI and ANSI has allowed for a smoother process in the claims submission.
All claims go through a clearinghouse, then are dispersed to the insurance carrier on the claim by the Payer ID on each CMS-1500 form. As a billing service, our responsibility is to follow the market and navigate the best way for claims to be submitted to insurance.
Patient’s insurance benefits
The first step in the claims process as a provider is the patient’s insurance benefits. The patient’s demographic information must be on the claim form as listed by insurance (full name, date of birth, sex, and address.)
On the back of the insurance card, it will list the payer insurance company to receive the insurance claims. Often for mental health claims, they are serviced by a third-party insurance company. This information can be obtained by calling the “Provider Services” phone number on the back of the insurance card.
MCM South offers Patient Insurance Benefits Verification as a service to assist your practice. Patient Insurance Benefits Verification is offered with the billing service and as a standalone service.
CPT or service codes
CPT Codes for Psychiatric Diagnostic Evaluation and Psychology Services (Non-E/M)
90791 Psychiatric Diagnostic Examination without medical services
90832 Individual psychotherapy (time range 16 – 37 minutes)
90834 Individual psychotherapy (time range 38 – 52 minutes)
90837 Individual psychotherapy (time range 53 – 60 minutes) **
*** There is no code for a 75-minute session *** 1
*** There is no code for a 90-minute session ***
90853 Group therapy
90846 Family psychotherapy (without the patient present)
90847 Family psychotherapy (conjoint psychotherapy) (with patient present).
ADDON CODES
+90785 Interactive complexity
+90839 Patient in crisis
+90840 Patient in crisis (each additional 30 minutes)
*90837 may require a special authorization by the individual insurance payer.
**Family visits can consist of spouses, parents and children, patients, and other family members
Claims Form
After the date of service or session is completed by the provider a claim may be submitted to insurance. Insurance assumes that the provider will collect the patient’s out-of-pocket responsibility, therefore, there is no place on the claim form to note how much was collected from the patient.
Depending on the provider’s system or software used to generate the claim form the below information will populate onto the CMS-1500 form.
1. Patient demographic information
2. Date of service and diagnostic code
3. Provider demographic information
All this information will be visible on the claim form, however, the information is transmitted to the clearinghouse by (EDI) electronic data exchange, in ANSI format. The clearinghouse, in turn, transmits claims to insurance electronically through EDI. The CMS-1500 form is used to submit mental health claims to insurance for out-patient procedures
Clearinghouse
The majority of all claims are processed through a clearinghouse. If not claims, are directly uploaded and processed by the insurance carrier.
Many providers or billing services use software or an EHR to manage providers’ calendars and patients’ demographic information. After the date of service has been performed the information is populated onto the claim form, which is then forwarded to the clearinghouse to be dispersed to the respective insurance company by the Payer ID on the CMS-1500 form.
The clearinghouse is useful in submitting clean claims to insurance and reducing processing times. A clearinghouse with “scrub” the claim to ensure that all the critical components are included on the claim form;
Patient demographic information
- Full name (first and last name)
- Date of birth
- Address
- Sex
- Member ID
- Claim components
- Diagnostic code
- Date of service
- Place of service
- CPT or service code
- Diagnostic pointer
- Charges or Bill rates for each CPT code
- Units of service
- Rendering Provider NPI
- Total Charges
Provider’s demographic information
- Provider full name (first and last name)
- NPI and group NPI (if applicable)
- SSN or EIN
- Service Location address
- Mail to address for provider correspondence
In the event any of the information is not included on the claim form, the claim will be “rejected” for the submitting party to correct, prior to the claim being submitted to insurance. This saves time in the claim process, as it could take days for insurance to “reject” a claim. And their process to re-submit a new claim is more elaborate.
In-network provider claims
All claims are submitted to the insurance company for processing. When the claim is received by insurance, they evaluate the provider’s network status against the claim. In the evaluation of the provider, review the demographic information on the claim form; full name, service location, mail to address, NPI(s), and the EIN or SSN.
In the credentialing application with an insurance carrier a provider will include all their demographic information;
- Provider full name (first and last name)
- NPI and group NPI (if applicable)
- EIN or SSN
- Line # 32 service location of service (cannot be a PO Box)
- Line # 33 mail to address for the provider correspondence (cannot be a PO Box)
This is the same information to be populated on each claim form for claim submission. If any of this information changes on the claim form, it will result in the claim being denied or processed as out-of-network. To update any of the provider demographic information, you must contact each insurance company and follow their protocol to update the provider demographic information.
Submitting non-credentialed or out-of-network claims
All claims are submitted to insurance, in the same manner, no matter the network status of the provider, whether they are paneled or not with an insurance company. The difference in how the claim is processed is completed by the insurance company in the adjudication process.
When the claim is received by insurance, they will review the provider demographic information against the patient’s benefits. In the review, insurance will determine how the patient’s benefits may be applied to the provider’s claims.
- If the patient has out-of-network benefits
- If yes, do they have a copayment or deductible (often the out-of-network deductible accumulates separately from the in-network deductible.)
- What is the “allowed rate” for the out-of-network service codes on the claim form.
- With the service codes on the claim form, reimbursement will be issued to the provider or the charges will be applied to the patient’s deductible, with no reimbursement.
Claim final adjudication
After insurance has reviewed the claim and made final adjudication they will issue reimbursement or the services will be applied to the patient’s deductible. The correspondence from the insurance company is in the form of an (EOB) Explanation of Benefits or its electronic version, known as an ERA or 835 files. The ERA file is forwarded electronically and allows the information to be uploaded to most software, versus manual data entry.
Claims submission made easier for your Practice
At MCM South Medical Billing Service, we can submit your claims to insurance, along with many EAP claims (Cigna or United Behavioral Health). Along with patient insurance benefit verifications, we can add value to your private practice.
Medical Billing Service services for Mental Health providers
At MCM South Medical Billing Service, LLC, we are a billing service for mental health providers. We understand the importance of ensuring that your medical claims are accurate, complete, and timely submitted. We work with various providers, including psychiatrists, psychologists, clinical therapists, and female therapists with specialties such as LPC, LMFT, LCSW, MD., Ph.D., and Psy.D to ensure that their claims meet the specific payer guidelines. Our therapists are in solo or group practice.
Services
– Comprehensive medical billing service
– Patient insurance benefits verification (offered as a standalone service)
Our therapists specialize in a range of areas, including anxiety, trauma, cognitive-behavioral therapy, child behavior, couples therapy, family therapy, play therapy, sports therapy, ADHD, and psychological testing. By providing comprehensive billing services, we can help providers focus on their areas of expertise while ensuring that their claims are submitted accurately and efficiently.
