Medical Claims. How to File a Medical Claim. Coordination of Benefits. Explanation of Benefits Instructions and Sample

Medical Claims

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How to File a Medical Claim Coordination of Benefits

How to File a Medical Claim

The majority of providers will supply, complete and file claim forms for most in-network and out-of-network services. In the event that a claim was not submitted by the provider, please note the group number and name of the insured on the form and forward to the designated claims office.

Coordination of Benefits (COB)

The COB provision is designed to allow the maximum payment for covered qualified changes by coordinating benefits available between multiple plans. This also results in a cost savings for the plan, which is the second payer on the charges. This, in turn, can result in reduced premium costs.

COB provides that for an employee covered under two or more plans, one plan will be primary and pay its normal benefits under the plan. Any other coverage(s) will be considered secondary and will pay up to the remainder left unpaid by the primary carrier.

Like many Plan provisions, the COB provision is occasionally revised to keep up with the ever-changing health care environment. If you have questions about how COB works, refer to your Group Policy/Plan or contact your claims service representative.

Medicare Handling

Like group insurance plans, Medicare provides health care coverage to many elderly and disabled individuals. To reduce the risk of over-insurance, Medicare coverage is taken into consideration when determining what Plan benefits are payable.

Medicare Secondary Payor Rules for Large Group Health Plans

Prior to August 10, 1993, Medicare was secondary to group health coverage under a large group health plan for those individuals who were entitled to Medicare because of their disability and who satisfied the criteria for "active individuals" as established by the Health Care Financing Administration. Effective August 10, 1993, OBRA '93 amended the law to delete references to "active individuals."

Under the revised law, if the individual is covered under the plan by virtue of his/her "current employment status," then the large group health plan may not take into account that the individual is entitled to Medicare. In essence, this means that the group plan will be the primary payor for disabled individuals who are actively employed. Medicare will be the primary payor for disabled individuals who are not actively employed.

To file a claim when Mutual is the primary carrier….

The employee should file his or her claim with Mutual as usual. A completed claim form and copies of bills should be included.

Remind the employee to make copies of bills to to file with the secondary insurance carrier. .

PRIMARY CARRIER (Mutual of Omaha)

The employee may use the Explanation of Benefits (EOB) he or she receives from us to File with the other insurance carrier when they are secondary.

SECONDARY CARRIER

file with

The employee should include copies of his or her bills to file with the secondary carrier as well Bill .

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Bi Bill Bill

Bill

Completed Claim Form

Bill

Explanation of Benefits

To file a claim if Mutual is the secondary carrier….

Employees should submit: 1. A completed claim form.

2. A copy of the EOB from the primary insurance carrier (e.g., Medicare EOB, etc.)

3. Copies of all bills to be considered for benefit consideration. Photocopies are acceptable.

SECONDARY CARRIER

(Mutual of Omaha)

Note: If Mutual of Omaha is the secondary carrier, we cannot consider benefits until the primary carrier has paid benefits and until we receive the copy of the primary of the primary carrier’s EOB

Note: Follow the same procedures for coordination of benefits when Medicare is involved

Bill Bill Bill

Copy of EOB from Primary Carrier Completed

Claim Form

Explanation of Benefits (EOB) Instructions and Sample

Field Field Name Description

1. For Inquiries Call The toll Free and Local phone numbers to use for customer service. 2. Date Date the claims were processed.

3. Page Page Number. 4. Direct Inquiries

To

The company name and the claims paying office. 5. Subscriber The subscribers name.

6. Group ID The Group ID.

7. Provider Name of the provider rendering services.

8. Member Name of the member the claim has been processed for.

9. Account No The patient account number provided by the provider of service. 10. Claim No Claim number assigned by company.

11. Reference No Unique ID number assigned at the claim level on subscriber’s EOB. 12. From Date Beginning date of service.

13. To Date Ending date of service.

14. Service Type Short description of the type of service rendered. For hospital claims submitted with revenue codes, the services will be shown as Room & Board, IP Misc or OP Misc 15. Submitted Charge The amount that was charged for the service.

16. Negotiated Savings / Write-Off

Dollar amount patient is not liable for. Includes: Clinical Editing when the plan and provider are PPO, Per Diem Claims, PPO Negotiated Savings, Multi Plan, Up & Up, Concentra, Risk Withhold, etc.

17. Charges Non

Covered Charges not covered due to policy exclusions, Usual and Customary reductions, planlimitations are also listed in this field. The patient is liable for amounts displayed here. 18. Note A two- or three- digit alpha/numeric code for which the reason charges were not

covered.

19. Note 2 If additional reason codes are needed, we can display up to 4 codes. 20. Note 3 If additional reason codes are needed, we can display up to 4 codes. 21. Note 4 If additional reason codes are needed, we can display up to 4 codes. 22. Co-pay Member co-payment amount.

23. Ded. Amount applied to the deductible.

24. Co-Ins. The difference of the allowable amount after the negotiated savings, non-covered charges, copay and deductible have been taken. This is the percentage difference that is the patient’s responsibility.

25. Benefit Amount The amount payable by our plan.

26. Patient Liability Patient out of pocket expenses. Includes non-covered services, co-payments, deductible amounts and coinsurance amounts. This amount may be reduced by the Coordination of Benefits with a Primary Carrier.

27. Claims Totals Column amounts for each field when more than one line item exists for a claim. 28. Total Considered

Charges Total amount allowed by the primary insurance carrier. 29. Other Carrier Paid Amount primary carrier paid

Field Field Name Description

after Coordination of Benefits

Note: Fields 28-32 will only display on the EOB when coordination of benefits has occurred.

33. Payment Summary: Subscriber Amount

Total amount paid to the subscriber for the claim.

34. Provider Amount Total amount paid to the provider for the claim. 35. Deductible

Information

Deductible yet to be satisfied for participating and non-participating providers. 36. Note Descriptions A detailed description for any notes associated to a line item.

37. Negotiated Savings/Write-Off Message

Negotiated savings amounts will not have a NOTE printed on the line item. When amounts display in this field, a generic message will print at the bottom of the subscriber’s EOB. “Savings negotiated by The Mutual of Omaha Companies with your provider of service. You are not liable for this amount.

38. Patient Liability Generic message printed at the bottom of the EOB.

39. Package ID The package ID number is used internally to access material.

40. Fraud Language Fraud language will print based upon the state where the subscriber resides. If the state mandates special wording, it will be pulled in otherwise a generic fraud statement will print.

41. Appeal Language Appeal language will print based upon the state where the subscriber resides. If the state mandates special wording, it will be pulled in otherwise a generic appeal statement will print.