Understanding Insurance: Claims Processing

Understanding Your Insurance Better

How are your claims processed at Elite and in what length of time?

When a provider submits a claim to an insurance company, there is specific information that is required by all insurance companies to identify the patient, the provider and the services provided.  Although it’s somewhat “encrypted” it’s important that all of the information is correct and accurate.  Providers you visit that will be filing these claims on your behalf will need to obtain your name as it is on your insurance card, your address, your date of birth, and your insurance identification number.  In some cases, depending on the policy type, they may also require your social security number and an insurance issued group number which is located on the insurance card.

Claims also include information that helps the insurance company identify the reason for the claim and how you arrived there.  There is identifying information on the claim that will notate whether it was an auto injury, work related injury or something else.  The diagnosis code, also called an ICD-10 code (International Classification of Diseases, Tenth Revision), is a series of three to characters that indicate what the injury or illness is, whether it affected the left side or the right side, the severity of the injury and/or whether it is an initial encounter or subsequent encounter.

In physical therapy practices, it is essential that a claim contain a procedural code, also called a CPT (Current Procedural Terminology) so the insurance company will know what services you received.  Without these, they will not know what they are paying for and how to adjudicate the claim and complete processing.

Once your treatment is complete, the provider will document the visit which will be translated into specific diagnosis and procedural codes to be forwarded to your insurance company in the form of a claim.  Some medical facilities/offices will submit these to the insurance company daily, while others submit weekly, bi-weekly or even monthly.  The insurance recognizes each of these claims in the order they receive them, rather than the order they actually occurred.  Example, you visit your primary care office on a Friday who files their claims weekly on Thursdays and are referred to an orthopedic who sees you on Monday and also files weekly, but on Wednesdays and the orthopedic refers you to imaging for an MRI that afternoon who files monthly and to physical therapy the next day who files claims daily.  In this case, your claim for Physical Therapy would likely process first, then the orthopedic, then the primary care and then the imaging center.  It is in this order that the patients’ responsible portion of the claim(s) will be accessed.

From the time the insurance company receives the accurately completed claim to the time they process it varies by insurance.  Your larger insurance companies such as BCBS, Aetna, Medicare, etc. will all process claims in an average of 3-4 weeks.  Smaller insurance companies are not bound to the same regulations and may not process the claim for up to 3-6 months.

If you are working towards a deductible on your insurance plan but think you are getting close and have multiple appointments coming up in a short period of time, you may want to consider asking them how frequently they process claims so you can do some of your own budgeting to be sure they are all being paid according to how the insurance company will process.

If you have an insurance plan and have met the deductible, or are only required to pay a coinsurance, the finite amount of your responsibility can only be estimated at the time the services are rendered and cannot be definite until the claim has actually processed which means smaller insurance carriers that don’t process claims for 3-6 months may leave you with a balance long after you received the services.

While any number of things can affect the claim process, and your providers’ offices are working hard to avoid any delays, you should expect them to ask you for some detailed information on or before your first appointment, and always contact the office for a better explanation if you don’t understand something.

In Physical Therapy, we will process claims with any and all needed diagnosis codes (ICD-10), procedure codes (CPT), your identifying information and our identifying information.  Elite Physical Therapy will process your claims within 2-5 business days from the date services were rendered and are always happy to help you understand the process, where each of your claims is in that process, and we will maintain contact with you to resolve any issues that may arise during the process to ensure everything is filed appropriately and timely.

If you have questions about your insurance, please call our office at the number below.