IV.

Verifying Insurance Coverage and Benefits

Information Needed for Verifying Patient Coverage When patients are referred by a physician or call for an appointment, important information that you will need to request from the provider or patient is listed below. A standard referral page or intake of information is often helpful in collecting the needed information. (**See page 60 Sample Referral Page)     

Patient’s Name (as it appears on their insurance card) Patient’s Date of Birth Patient’s Insurance Company Patient’s Insurance Company’s Provider Telephone Number Patient’s Policy Number o If this is the only insurance that the patient has, follow to the next question. o If the patient has more than one insurance company, obtain the above information for each policy. o You will need to file with the patient’s primary insurance policy first. If you are not credentialed with the primary insurance company, you will have no way to file that policy and therefore will not get a primary denial and will not be able to file the secondary insurance. (**See page 76 Filing Primary and Secondary Insurance Claims) Example: The patient has Medicare as their primary insurance and Blue Cross Blue Shield Federal for their secondary insurance. You are not credentialed with Medicare and are credentialed with Blue Cross Blue Shield. You will not be able to get a primary denial from Medicare because you will not be able to file that claim; therefore you will not be able to file the secondary insurance. If you file the secondary insurance without filing the primary, the patient’s Explanation of Benefits will return with non-payment awaiting explanation from the primary insurance.

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Referring Diagnosis or any other diagnosis that the patient may have (It is often helpful to request a Medical History page when patient is being referred from a physician. Some policies may not pay for the referring diagnosis, but may pay for other conditions that the patient may have. Note: Some policies will want a copy of the physician’s referral and if the ‘covered’ diagnosis is not listed on the written referral, the claim will be denied.) Example: A Blue Cross and Blue Shield Federal patient may have been referred with ICD code 278.01 - Morbid Obesity, but the physician may not have noted that the patient is also Diabetic 250.00 with Gastric Reflux 530.81 and has Hypercholesterolemia 272.0. Blue Cross and Blue Shield Federal will pay for the Gastric Reflux and Hypercholesterolemia. A Blue Cross Blue Shield Out-of-State Policy may only pay for Nutrition Therapy for Diabetes 250.00, but the patient was referred for Morbid Obesity 278.01. The insurance will not pay for the claim if you use Morbid Obesity as your ICD code when billing. If you file the claim with a Diabetes code and they ask for documentation including the Physician’s referral and it is not documented that the physician referred that patient for Diabetes and that you discussed their diabetes with them in your notes, this claim will be denied.

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Calling the Patient’s Insurance for Verifying Patient Coverage & Benefits In a large clinic or practice, verifying a patient’s insurance coverage for MNT will increase your billings and decrease a large bill for the patient. For a small practice, calling the patient’s insurance company for each and every patient to verify coverage is critical. If a patient is scheduled for an appointment without verifying the coverage, the patient may be liable for a large bill and/or the practice may have to pursue this patient for payment. Verifying coverage for each patient will not constitute a guarantee of payment (which is noted with a recording or representative each time you call), but will improve your chances of reimbursement. With some policies you may be very familiar with the benefits for the patient, but you will still want to ensure that the policy is still an active policy, that there are not any pre-existing clauses on the policy, or that the patient is enrolled in any appropriate programs (ex. Member Health Partnerships)  Call the patient’s insurance company with all of the patient’s information available.  Note: o Date and Time of Call o Representative you speak with o Is this policy active?  Does the patient have benefits for Procedure Codes 97802 (Initial MNT) and 97803 (Follow-Up MNT)?  Is the patient’s diagnosis/condition covered under the plan? - If you are not credentialed with the insurance company, ask… o If they pay for out-of-network services? If “No”, then ask if there is a reference number for the call. If “Yes”, proceed to the questions below.

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- If you are credentialed, ask… o Is there a referral needed? o Is there a deductible? o Is there a co-pay or co-insurance? o Is there a limit to the number of visits? o Is there a limit to the length of visit (units)? o Are there any exceptions? Note a reference number for the call. Some representatives will suggest you use their name and date/time of the call. If they are in another state, you may ask what time it is in that state.

Example: Verification of Insurance

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Patient’s First Visit On the patient’s first visit, you will need to collect general demographic and health information from the patient, if you are seeing the patient independently. If you are a part of a practice, all of this information should be available in the patient’s chart. Demographics  Full Name  Mailing Address  Contact Numbers (Home, Work, Cellular)  Alternate Contact (Email, Pager)  Gender  Date of Birth and Age  Social Security Number Health Information  Weight Loss History  Medical History  List of Medications If you are in private practice, due to fraud issues, you will need to collect a copy of the patient’s insurance card (front and back) and a copy of the patient’s driver’s license (must be black and white, no color copies) or other photo ID to verify that the patient is indeed the patient presenting the insurance card. If you work in a large practice and think you may need to talk to providers outside your clinic or network, check with your clinic manager whether you need to collect a Medical Record Release. You should know the office policies including insufficient fund fees, noncovered charges by the insurance company, collection fees, or no show fees. If you are in private practice, as part of your intake paperwork, you may also collect a Medical Record Release allowing you to talk to any physicians, specialists, or family members. It will also be important to disclose any financial or office policies including insufficient fund fees, non-covered charges by the insurance company, collection fees, or no show fees.

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Example: Referral Page

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Electronic Claims Submission Services - Verifying Benefits with Blue-e (BCBSNC) With Blue Cross and Blue Shield of North Carolina, you have the option to file your claims using Blue-e versus batch filing or using a filing service. Blue-e is a quick and easy method for filing all of your Blue Cross Blue Shield claims. If you are filing with more than one insurance company, you may choose to use another method of filing. Signing up for this service does not require you to use this service for filing your claim. This service can be very beneficial for verifying benefits. With Blue-e, you will sign up to use this benefit: http://www.bcbsnc.com/content/providers/edi/bluee/signingup.htm You can go for a tutorial using: https://providers.bcbsnc.com/providers/_help/demo/cms1500_add_claim/cms1500_add_ claim.htm  Once signed in, go to “Eligibility”: Enter the member number and/or the member last name, first name, and date of birth. A member number, name, and date of birth are required to search for FEP or out-of-state members. You may enter a single date for the date of service, or if left blank, it will search on today's date. 

On the Eligibility page, you will see two tabs “Member Information” and “Benefits” Member Information TAB to see important information including: o Under Member Information, you find the patient’s information including name, address, DOB, and relationship to subscriber.

Under policy information, you find the patient’s benefit period which is listed under Effective Date. This will be when the patient’s policy renews each year. (This will affect the patient’s annual deductible or annual number of visits.) Example of Information: Eligibility for 07/01/2009 - 12/31/9999 Member Information Remember, the benefits you see on this screen are a summary of member benefits and do not indicate payment when a claim is filed. Member Information Member Number: YPPW1234567890 Name: Date of Birth: JANE DOE 12/8/1967 Address: Sex: 300 HAPPY STREET Female Rel. to Subscriber: HEALTHY, NC 12345 SPOUSE Policy Information Product: Effective Date: BLUE OPTIONS 07/01/2009 Paid Through/Term Group Number: 012345 12/31/9999 Date: Group Name: TOWN OF HEALTHY BLUE OPTIONS-Underwritten Insurance Type: Group

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Under member liability summary, you can see what the patient’s deductible is and how much the patient has met of their deductible. (This will be helpful for patients who must meet their deductible before services are covered.)  Under COB (Coordination of Benefits) summary, this will either be blank or read “See Other Insurance Tab”  Under Additional Information, Pre-existing Condition Waiting Period would be listed or No Pre-existing Condition Waiting Period

Example of Information: Member Liability Summary In-Network Single Max per Coverage Benefit Period CoInsurance 40% $3000.00 Deductible $1750.00 Out-Of-Pocket $4750.00 Out-ofNetwork Coverage CoInsurance 60% Deductible Out-Of-Pocket COB Information:

Single Max per Benefit Period $6000.00 $3500.00 $9500.00

Family Max per Benefit Period $9000.00 $5250.00 $14250.00

Year-to-Date Remaining $3000.00 $1528.83 $4528.83

Year-to-Date Remaining $9000.00 $5028.83 $14028.83

Family Year-to-Date Remaining $6000.00 $3278.83 $9278.83

Max per Benefit Period $18000.00 $10500.00 $28500.00

Year-to-Date Remaining $18000.00 $10278.83 $28278.83

No other insurance information on file.

Additional Information: Pre-existing Condition Waiting Period 06/07/2006 to 06/07/2006

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Benefits TAB Under the Benefits tab, click “General Benefit Information”, and then “Other Medical” to see Nutrition Benefits. If there is a copay, coinsurance, or deductible, you will see it listed. This is an example of a Blue Options policy:

Nutritional Counseling Diab In Dmp INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR Nutritional Counseling Diab Not In Dmp In Network COINSURANCE: 40% per SERVICE YEAR Nutritional Counseling INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR Nutritional Counseling Out of Network Diab No Dmp COINSURANCE: 60% per SERVICE YEAR Dmp = Diabetes Management Program

Verifying Benefits with Webclaims (Medicaid) With Medicaid, you also have the option to file your claims electronically versus batch filing or using a filing service. Again, you may only use this service to verify benefits. To sign up, visit NC Tracks web site at http://www.nctracks.nc.gov/provider/forms/. You will complete and Electronic Claims Submission (ECS) Agreement for Individuals or Groups. Once you have signed up for this service, you will go to https://webclaims.ncmedicaid.com/ncecs/ to sign in and review patient benefits and claims.

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