Once the HCFA/CMS 1500 is generated and checked for accuracy, it should be transmitted to the applicable claims office. Timely filing is mandatory, since third-party payers generally require filing within one year of the date of service. A provider should develop its own directory of those companies and contact persons with which it conducts substantial activity. Under ideal circumstances, the filing office will settle within three to six weeks.

NOTE: For dates of service on or after July 1, 2005, providers must bill the EI-CBO within 90 days of the date of service or within 90 days from the last communication from the insurance company.

With an assignment of benefits, obtained as part of the parent consent/participation, the provider should be paid the appropriate insurance proceeds. Most plans will enclose an explanation of benefits (EOB) to explain the calculations involved in the process. (See samples at end of this chapter. Note the differences in the informational content provided. You will also find varying degrees of consumer orientation and customer service within the third-party financing system.)

Follow-up with the third-party payer is required when:

  • it is necessary to respond to requests for clarification or additional information
  • an unusually long period of time has elapsed after the claim is filed without a response, or
  • the response is inadequate

Inquiries from third-party payers may include questions regarding an incomplete or inaccurate form, or requests for additional records to document or support the information submitted.

It is only through trial and error that the provider's insurance representatives can become proficient in the effective follow-up process with their third-party counterparts. It is helpful if the provider's third-party specialist has knowledge of insurance terminology, claims processing methods across plans, and benefit structures of private and public plans.

An insurance representative must learn how to deal with all aspects of each problem. Most situations regarding problems of private plans can be resolved over the telephone with the insurance plan's adjuster.

It is the responsibility of the provider's insurance representative to audit insurance claim payments to verify that the maximum benefits have been paid. If there is a question concerning payment, contact the plan's adjuster. Perhaps with additional documentation, an adjustment will be made. If there is a question of benefits payable, request that the claim's adjuster send a copy of the plan booklet/document.