Provider and Patient Setup

Before Sending a Claim

Before a provider can file a claim for their encounter with the patient, there are certain authorizations that must be obtained and information collected:

1. Provider (physician) must be credentialed with insurance payers.
2. Provider must be enrolled with insurance companies to send claims electronically.
3. Patient personal information collected.
4. Patient insurance information collected.
5. Patient authorization for provider to submit claims on their behalf.

Practice Management Software

Just about every healthcare provider uses a practice management software to manage their practice. There are hundreds available. Practice management and medical billing software are used interchangeably. Just about all of them can perform the same basic functions:

• Scheduling patient visits
• Managing patient accounts
• Creating insurance claims
• Recording insurance and patient payments
• Creating patient statements
• Tracking claim status

Provider info Entered in Practice Management Software

CMS-1500 Claim Form

• The most important form in medical billing in both its paper and electronic form.
• Contains all the information from the patient encounter in one form.
• The CMS-1500 form was developed by the National Uniform Claim Committee (NUCC).
• NUCC is responsible for standardizing instructions for completion of the form.

Patient Information Form

Patient Insurance Card

Patient Insurance Info Entered in Practice Management Software

Patient Encounter Code Entry in Practice Management Software

Other Important Forms

The following forms are required on the first patient visit to obtain all the necessary information and authorization to bill for the visit:

• Patient Information which includes Insurance, Guarantor, Assignment of Benefits, Payment Authorization
• Authorization for Release of Medical Information
• Patient Medical History
• PHI Acknowledgment of Receipt of Privacy Policy
• Payment Policy
• HIPAA Communication Disclosure

MS Word templates of these and many other forms are included with the Fundamentals Course

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