2. INTRODUCTION
In order to make sure that our
insurance claims get paid in a timely
manner, we will be doing a step-bystep instructional.
Following these
guidelines is crucial.
3. AGENDA
Intake & update information
Inputting into Pinnacle is critical
Rules & regulations for submitting claims
When a claim is rejected
Sharepoint & EOB’s
Patient balances
Write offs & collections
4. INTAKE & UPDATE INFORMATION
It is important to get as much information
on a patient. Name, Address, Phone, Date of
Birth, Physician, Insurance & referral
source.
All intake forms must be from HearingLife –
Intake, Financial & HIPPA. The patient must
sign all of them.
If existing patients haven’t signed HL forms
they need to update their records. Get
copies of insurance cards to make sure they
are current.
5.
For existing patients ask to see their
insurance cards & if anything (address,
etc) has changed since their last visit.
Make copies of all insurance cards & date
them. Put this in the patients chart.
Use the insurance verification form (found
in Sharepoint) for details on benefits. Note
who you spoke with and obtain call ID # if
possible.
8. It is imperative the patient signs
financial policy & checks the
financial responsibility box on
intake form
9. INPUTTING INTO PINNACLE IS CRITICAL
If information isn’t entered into Pinnacle
accurately a claim will get rejected.
No hyphens, hashtags, commas, periods,
etc. are allowed except in phone number,
date of birth & social security fields.
All boxes should be checked especially the
gender & HIPPA waiver signed (make sure
patient signed this).
10.
Add patients primary care physician &/or
ENT in details blade.
When entering insurance information be
careful to chose the correct one in the
insurance manager section.
Patients can not have Medicare and a
Medicare Advantage policy. Any Medicare
Advantage policy takes place of Medicare.
Patient information entered MUST match
exactly as their insurance cards!
11.
If the patients insurance is under their
spouse or parent, then the insured’s name,
date of birth & gender must be entered in
the insurance manager, not the patients.
Make sure you are selecting the correct
Insurance name & address in Pinnacle.
12.
Please document when a referral &/or
Medical Clearance is received, by who and
the date in the Notes section under the
details tab. (Important for those working in
the insurance department).
15. RULES & REGULATIONS FOR SUBMITTING CLAIMS
Use the insurance verification form to
determine the patients insurance benefits.
Make sure you document date/time &
persons name you spoke with. If possible,
get call ID #.
When creating an order that will be
submitted to insurance you must chose
“Yes” when Pinnacle asks if this order will
be paid by insurance.
16.
Audiologists must make sure there is a
referral from a PCP (primary care physician)
prior to doing a hearing test (self referrals
not allowed).
Medical Clearances must be obtained prior
to fitting patients with hearing aids. Verify if
M.C. must be from a DO, MD or ENT. If
patient received clearance at a different
facility, try to get copy by using records
release form. DO NOT PROCEED WITH
DELIVERY IF M/C HAS NOT BEEN
RECEIVED!
23. #1
#2
#3
• Enter Claim Information
• Submit to Clearinghouse or Create Outside System
Claim if it is a 3rd Party Claim ie: TruHearing
• Check back for notes from biller & correct mistakes if
necessary. Let biller know once errors are corrected so
they can resubmit
• Biller will close claim after receiving EOB/Payment.
• Invoice patient any remaining balance or refund if it is
due.
24. When a Claim is Rejected
You will know if a claim was rejected either
from the biller or an EOB (Explanation of
Benefits).
Check the notes section of an order as this
is typically where the biller will note details
about claim.
25.
At no point are you to hit the “Process
Claim” button. Only the biller is allowed to
do this.
At no point can you submit a claim to the
Clearinghouse for secondary insurances.
Only the biller can do this.
At no point should you reject a claim &
reprocess it. This creates a problem at the
billing end.
29. PATIENT BALANCES
Once a claim is completed the biller will
process it and mark it closed. If there is a
patient balance- be it a coinsurance, copay,
deductible or balance bill amount you then
print out a receipt/statement & send to the
patient.
Find a system that works for you to keep
track of patient balances. Petoskey has a
“tickler file” labeled Patient Invoices.
30.
Find a system that works for you to keep
track of patient balances. For instance, when
printing out invoices you can print two. One to
send to the patient and the other to keep in
the invoices file.
Petoskey uses labels to put on invoices that
say “Your insurance has indicated that the balance
due is part of your deductible, copay or
coinsurance. Please refer to your recent
Explanation of Benefits that you received from your
insurance company for details. Balance is due upon
receipt – Thank you.”
31.
32.
You can send out statements from Pinnacle.
Go to Administrator, then scroll to Accounts
Receivables/Collections.
34. HEARINGLIFE PROTOCOL FOR PATIENT
BALANCES
1. Once insurance has paid their portion and there is a patient balance, immediately
send a statement.
2. You must note in Pinnacle on the patient order, in the Notes blade, the date that
the statement(s) were sent.
3. After 30 days, phone patient and send 1st demand letter- available on SharePoint.
You must note in Pinnacle on the patient account the date that the letter was
sent. (Keep copy of letter(s) in patient chart)
4. After 60 days, phone patient and send 2nd demand letter- available on
SharePoint. You must note in Pinnacle on the patient account the date that the
letter was sent.
5. After 90 days, phone patient. Work with accounting to send a 3rd and Final
Demand letter. You must note in Pinnacle on the patient account the date that
the letter was sent.
6. Once the 3rd and Final Demand Letter is sent, consult with Michelle & Liz
regarding the use of a collection agency. Only the Senior Accountant can send
accounts to collections.
7. You can not tell accounting to write off a balance without your RVP’s
written consent!
Editor's Notes
The more information the better. Signing all forms is crucial.
Insurance contract numbers are always changing. Ask patients to see their cards & note any changes &/or additions, deletions in Pinnacle. By dating the page in chart that has copy of insurance cards, you will remember when you last confirmed contract numbers & insurance plans
All HearingLife forms are found in Sharepoint under the Sales tab – Professional Forms
If a question arises about a referral and/or medical clearance, this information will be very helpful if there is an issue with claim regarding these particular issues. It saves time asking PCC.
The more detail the better. All radio buttons chosen correctly & boxes at the Privacy section are chosen. Claims will not go through if HIPPA Waiver Signed box is not checked. Can not check it unless patient has signed the form which must be kept in the patients chart
Go to the Order ID that you will be creating claim for
In the actual order . . .All items must be marked fitted with the date patient rec’d them.
Once item(s) have been marked fitted, go to the claim blade & select “add a claim”
Make sure all fields are accurately filled out. Be mindful of the insured’s information if different from the patients.
Date of referral/medical clearance. GY modifier is used if Medicare is primary and item is a non-covered medicare service. Medicare will process and forward to secondary insurance.
Facility & Provider NPI is HearingLife’s – 1366628166. Physician Name & Physician NPI is either your Audiologist or Michelle Giddings if you bill under her. Save claim first and then submit to Clearinghouse. (they will be green). **NOTE: DISPENSERS SHOULD BE GETTING THEIR OWN NPI
