Medicare process for claims for non medicare provider
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I am a dietitian and need to submit to secondary insurance for coverage, medicare has denied the claim and the secondary also denied the claim.  What steps do i need to take to reattempt submission?

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    Dustin

    Hi Beth,

     

    You've done the right thing by sending the claim to Medicare, even though you are not an in-network provider for Medicare. it sounds like you attempted to submit the secondary claim electronically through SimplePractice. If so, unfortunately our secondary claiming process is not working correctly, at this time. In this case it will better to file secondary claims outside of SimplePractice so that you can include a copy of the EOB (Explanation of Benefits) from the primary payer to prevent denials or rejections for invalid information. We do attempt to attach the payment report from the primary payer when submitting the secondary claim, however since we take the payment report and change it a bit to make it more readable, we are finding that it doesn't transfer to secondary insurance companies in a way that is legible for them. Therefore, they reject or deny the claim because they aren't sure exactly how much the primary insurance payer has already paid for each date of service.

     

    Now that Medicare has processed and denied the claim, you can use our system to create and download the secondary claim. Next, I recommend submitting the secondary claim to the payer with a copy of the authentic EOB from the primary Medicare plan (should have letterhead from the primary plan). Please refer to the following guide for the steps to download a claim: Creating and printing a CMS 1500 (HCFA) claim form To get a copy of the authentic, paper EOB so that you can mail it in with the secondary claim, please call the insurance company's Provider Services line to request that they mail you the paper EOB. Please be aware that paper claim submission rules vary based on the payer. I do know that they will always require you to attach a copy of the EOB or ERA and they may request that you send in the claim on an original CMS1500 claim form. This means that you'd want to buy a package of blank CMS1500 claim forms, then load those in to the print to print the claim fields onto the forms. Beyond that, you'll want to contact the insurance company directly to clarify whether there are any additional steps necessary for submitting secondary claims.

     

    I know that filing these claims manually is not the most efficient workflow but thank you for your understanding. The unfortunate reality is that many of our customers choose not to accept secondary insurance, since most insurance companies make it cumbersome to submit secondary claims. We are doing our best to build a way to automate this process but we are having difficulty with finding a way that all secondary insurance companies will accept the primary insurance payment reports that we send. We recently added a tool on our end that will allow us to start researching secondary claims that are processing correctly as some customers have experienced success with particular payers as the system is currently set up. Once we understand better we can implement changes that will hopefully allow secondary claims to work for the majority of payers rather than the minority, as it is. Thank your for your patience and understanding while we work to automate this process.

     

    Best,

    Hi Beth,

     

    You've done the right thing by sending the claim to Medicare, even though you are not an in-network provider for Medicare. it sounds like you attempted to submit the secondary claim electronically through SimplePractice. If so, unfortunately our secondary claiming process is not working correctly, at this time. In this case it will better to file secondary claims outside of SimplePractice so that you can include a copy of the EOB (Explanation of Benefits) from the primary payer to prevent denials or rejections for invalid information. We do attempt to attach the payment report from the primary payer when submitting the secondary claim, however since we take the payment report and change it a bit to make it more readable, we are finding that it doesn't transfer to secondary insurance companies in a way that is legible for them. Therefore, they reject or deny the claim because they aren't sure exactly how much the primary insurance payer has already paid for each date of service.

     

    Now that Medicare has processed and denied the claim, you can use our system to create and download the secondary claim. Next, I recommend submitting the secondary claim to the payer with a copy of the authentic EOB from the primary Medicare plan (should have letterhead from the primary plan). Please refer to the following guide for the steps to download a claim: Creating and printing a CMS 1500 (HCFA) claim form To get a copy of the authentic, paper EOB so that you can mail it in with the secondary claim, please call the insurance company's Provider Services line to request that they mail you the paper EOB. Please be aware that paper claim submission rules vary based on the payer. I do know that they will always require you to attach a copy of the EOB or ERA and they may request that you send in the claim on an original CMS1500 claim form. This means that you'd want to buy a package of blank CMS1500 claim forms, then load those in to the print to print the claim fields onto the forms. Beyond that, you'll want to contact the insurance company directly to clarify whether there are any additional steps necessary for submitting secondary claims.

     

    I know that filing these claims manually is not the most efficient workflow but thank you for your understanding. The unfortunate reality is that many of our customers choose not to accept secondary insurance, since most insurance companies make it cumbersome to submit secondary claims. We are doing our best to build a way to automate this process but we are having difficulty with finding a way that all secondary insurance companies will accept the primary insurance payment reports that we send. We recently added a tool on our end that will allow us to start researching secondary claims that are processing correctly as some customers have experienced success with particular payers as the system is currently set up. Once we understand better we can implement changes that will hopefully allow secondary claims to work for the majority of payers rather than the minority, as it is. Thank your for your patience and understanding while we work to automate this process.

     

    Best,

  • 1
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    Kristen Roudebush

    Hi

    I am not a provider of Medicare but still need to bill them for a reimbursement for VOC (Victims of Crime in California). I cannot figure out how to create a CMS 1500 within SP since they are not listed in the pull-down of * Insurance Payers. I was told that the contract in California is held by Noridian, but that is also not listed. Please advise.

     

    Kris

    Hi

    I am not a provider of Medicare but still need to bill them for a reimbursement for VOC (Victims of Crime in California). I cannot figure out how to create a CMS 1500 within SP since they are not listed in the pull-down of * Insurance Payers. I was told that the contract in California is held by Noridian, but that is also not listed. Please advise.

     

    Kris

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    Michele R. Hahn

    I'd like to know the answer to Kristen R's question as well. 

    I'd like to know the answer to Kristen R's question as well. 

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    Ashley

    Hi Kris and Michelle, 

    We currently don't have a connection to submit claims electronically to Crime Victims of California. I've put in a request with our clearinghouse to try and establish a connection. Each payer has specific requirements for creating a filing connection. If the clearinghouse is able to create the connection, I will follow up with you through a separate email.

    I'd recommend adding Crime Victims to your Insurance Payers list and then you can assign this payer as your clients insurance and create claims to submit outside of SimplePractice. 

    Please refer to the following guides for the steps to add a payer and to download a claim:

    If I can be additional help, please let me know.

    Hi Kris and Michelle, 

    We currently don't have a connection to submit claims electronically to Crime Victims of California. I've put in a request with our clearinghouse to try and establish a connection. Each payer has specific requirements for creating a filing connection. If the clearinghouse is able to create the connection, I will follow up with you through a separate email.

    I'd recommend adding Crime Victims to your Insurance Payers list and then you can assign this payer as your clients insurance and create claims to submit outside of SimplePractice. 

    Please refer to the following guides for the steps to add a payer and to download a claim:

    If I can be additional help, please let me know.

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    Lynn Hunsicker

    Hi - 

    I need to submit claims to Medicare, but the provider is not Medicare eligible.  Since I don't have a PTAN, Simple Practice will not let me create an enrollment. 

    Medicare does not accept paper claims. 

    So, how can I submit the claims to Medicare, to get the formal denials, to be able to submit them to the secondary payer ?

    Thanks !
    -Lynn.

    Hi - 

    I need to submit claims to Medicare, but the provider is not Medicare eligible.  Since I don't have a PTAN, Simple Practice will not let me create an enrollment. 

    Medicare does not accept paper claims. 

    So, how can I submit the claims to Medicare, to get the formal denials, to be able to submit them to the secondary payer ?

    Thanks !
    -Lynn.

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    Mary K. Crawford

    Lynn,

    Did you ever find out how to do this? I have a client who has Medicare with a BCBS PPO. Someone told me to do a coordination of benefits form for the PPO and send it with the claim, but this doesn't seem right. 

     

    - Kate 

    Lynn,

    Did you ever find out how to do this? I have a client who has Medicare with a BCBS PPO. Someone told me to do a coordination of benefits form for the PPO and send it with the claim, but this doesn't seem right. 

     

    - Kate 

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    Lynn Hunsicker

    Hi Kate - 

    No, I didn't get an answer to this one.  But, there is a webinar today (6-11-20) for "ask a biller"... and I'm hoping to get this answered.

    I've tried with other practices to submit a form with the claim stating that the original was denied, for what ever reason, but, they wouldn't accept it, as they required the actual denial from the primary.

    So, I'm kind of at a loss as to where to go now.
    If I get an answer today, I'll be sure to update you.  :)

    Hi Kate - 

    No, I didn't get an answer to this one.  But, there is a webinar today (6-11-20) for "ask a biller"... and I'm hoping to get this answered.

    I've tried with other practices to submit a form with the claim stating that the original was denied, for what ever reason, but, they wouldn't accept it, as they required the actual denial from the primary.

    So, I'm kind of at a loss as to where to go now.
    If I get an answer today, I'll be sure to update you.  :)

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    Ruth

    Hi Lynn and Kate - I’ve created help requests on your behalfs so that one of our Insurance Specialists can further assist you. They’ll be reaching out to you with their recommendations over email.

    Hi Lynn and Kate - I’ve created help requests on your behalfs so that one of our Insurance Specialists can further assist you. They’ll be reaching out to you with their recommendations over email.

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    Lauren Sullivan

    I'm in the same boat as Lynn H.  Would love to hear if anyone finds a solution. 

    I'm in the same boat as Lynn H.  Would love to hear if anyone finds a solution. 

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    Ruth

    Hi Lauren - If you'd like us to investigate a specific client, claim, or account setting, please submit a Help Request from your SimplePractice account. To do so, click on the "?" icon to the bottom right > Get Help > Ask Question > Email. You can also click here to submit a Help Request: SimplePractice Help Request Form.

    Hi Lauren - If you'd like us to investigate a specific client, claim, or account setting, please submit a Help Request from your SimplePractice account. To do so, click on the "?" icon to the bottom right > Get Help > Ask Question > Email. You can also click here to submit a Help Request: SimplePractice Help Request Form.

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    KEITH WASHINGTON

    Is any going to answer this question from Lynn H.May 27, 2020 14:18??? I need this info also ASAP.

    Is any going to answer this question from Lynn H.May 27, 2020 14:18??? I need this info also ASAP.

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    Ruth

    Hi Keith - Since there are many different kinds of Medicare Payer IDs and reasons for enrollment, or claims denials, the answer can vary. This is why I put Lynn in touch with a member of our Customer Success Group to investigate her particular case. I'd encourage you to also reach out to our Customer Success Group by clicking on the "?" icon to the bottom right of your SimplePractice account > Get Help > Ask Question > Email. You can also get in touch by clicking on this link: SimplePractice Help Request Form.

    Hi Keith - Since there are many different kinds of Medicare Payer IDs and reasons for enrollment, or claims denials, the answer can vary. This is why I put Lynn in touch with a member of our Customer Success Group to investigate her particular case. I'd encourage you to also reach out to our Customer Success Group by clicking on the "?" icon to the bottom right of your SimplePractice account > Get Help > Ask Question > Email. You can also get in touch by clicking on this link: SimplePractice Help Request Form.