Claims

1
Claims Billing Management

• Processing Third Party Claims

2
Interim Federal Health (IFH)

• IFH is an insurance company that supports
  refugees in the interim period before they
  receive Ontario Health coverage.
• IFH provides only essential and emergency health
  services for the treatment and prevention of
  serious medical conditions, contraception,
  prenatal and obstetrical care.
• Other services may require prior approval. (ex
  allergy testing, annual health exams)

3
Managers Responsibility

• Ensure forms are complete with all patient
  information and a photocopy of the landing papers
  (photo) is attached
• Ensure physician has entered billing codes and
  signed the form
• Enter a Third Party Billing claim into PPN
• Photocopy the IFH form and file it in the IFH
  Pending Payment folder

4
Managers Responsibility (cont)

• Send the completed original claim form along with
  a copy of the picture to
• IFH Program Priority Processing
• FAS Benefit Administrators Ltd.
• 9707-110 Street, Suite 901
• Edmonton, AB
• T5K 2W8

5
Blue Cross- RCMP DND

• Members of the RCMP and Department of National
  Defense are insured by Blue Cross
• OMA rates are applied to the physicians billing

6
Managers Responsibility

• RCMP
• Ensure Part A of form is completed by the RCMP
  member
• Ensure the physician has completed Part B of the
  form
• Enter a Third Party Claim into PPN
• File Copy 4 (Practitioners copy) in your Blue
  Cross Pending Payment folder
• Mail copy 2 and 3 to the RCMP office

7
Managers Responsibility (cont)

• HSO RCMP Health Services
• C-129 L-H Nicholson Bldg.
• 1200 Vanier Parkway
• Ottawa, ON
• K1A 0R2

8
Managers Responsibility

• National Defense
• Ensure National Defense member has filled in
  Health ID and service Number (located on the
  members Health ID card)
• Ensure Provider information is completed
• Enter number 6 for medical services under the POC
  column
• Ensure date and OMA fees are documented on the
  form the MD has completed the clinical
  observation section

9
Managers Responsibility (cont)

• Enter a Third Party Claim in PPN
• File copy 2 (Providers copy) in the Blue Cross
  Pending Payment folder
• Give copy 4 to the ND member
• Mail copy 13 to
• Canadian Forces Support Unit (Ottawa)
• National Defense Medical Centre
• 1745 Alta Vista Drive, Ottawa, ON K1A 0K6

10
Sunlife-Univ. Health Ins. Plan

• UHIP was created to offer affordable insurance to
  pay the cost of the hospital and medical services
  that the patient and the patients family might
  need to maintain their health while at a
  participating university in Ontario
• OMA rates apply

11
Managers Responsibility

• Ensure UHIP member has filled in sections 1,2 3
  on the claim form
• Photocopy the patients ID card and staple it to
  the claim form
• Ensure the physician has completed the billing
  section and signed the form
• Photocopy the form and file it in UHIP Pending
  Payment folder
• Enter a Third Party Claim in PPN

12
Managers Responsibility (cont)

• Mail the original form to
• Sun Life Assurance Company of Canada
• Claims Department
• PO Box 9845 STN T
• Ottawa, ON K1G 6V4

13
Cowan Wright Beauchamp

• Embassy Claims
• Photocopy the patients ID card and staple it to
  the claim form
• Process the same as UHIP
• Mail form to
• Cowan Wright Beauchamp
• 641 Montreal Rd
• Ottawa, ON K1K 0T4

14
WSIB

• When a worker injures themselves at work and
  presents themselves to the center, a Form 8 must
  be completed
• WSIB will be billed directly for the completion
  of the form
• The patients visit will be billed to WCB through
  OHIP

15
Managers Responsibility

• Ensure the Form 8 is completed and signed by the
  physician
• Mail or fax the form to
• Workplace Safety and Insurance Board
• 200 Front Street West
• Toronto, ON M5V 3J1
• Fax [phone] or 1-416-344-4684

16
Managers Responsibility (cont)

• Enter a Third Party Claim into PPN using WSIB
  Fee Schedule for appropriate prices
• PRE RECONCILE WSIB CLAIMS ONLY
• File the report in WSIB Pending Payment folder
• Ensure the claim for the visit is billed
  correctly under WCB (through OHIP) in PPN

17
Reconciling the Cheques

• When the cheque arrives for a third party claim
• Apply the payment to the claim so there is a 0
  balance
• Pull the appropriate form from the Pending
  Payment folder
• Staple a copy of the receipt to the form and file
  it in the patients chart
• Give the cheque and a copy of the receipt to the
  physician and have him sign the managers receipt
  for receipt of payment

18
Tracking Your Payments

• Each month, the pending folders should be checked
  for outstanding payments
• Contact the appropriate 3rd party if payments
  have not been received in a suitable time and
  inquire about status of payment

19
Attending Physician Statements

• An APS is a request from an Insurance Company for
  information on a patient from a physician
• Appletree charges a flat rate of 150.00 per
  request and requires pre-payment before a
  physician fills the request

20
Managers Responsibility

• Ensure the staff know how to identify an APS and
  bring it to the manager promptly
• Ensure the patients chart is available or have
  it retrieved from archives if necessary
• Enter a Third Party Claim into PPN for 150.00
• Send a copy of the receipt as an invoice to the
  appropriate Insurance Company

21
Managers Responsibility (cont)

• File the APS in the APS Pending Payment folder
• Once the cheque arrives, apply the payment
• Give the cheque, 2 copies of the receipt, (one to
  be signed and returned to the manager), the APS
  and the patients chart to the physician for
  completion

22
Managers Responsibility (cont)

• Once the APS is complete, photocopy all pertinent
  documents and the APS and file in the patients
  chart
• Mail to the appropriate Insurance Company

23
Third Party Billing

• Open BILLING module
• It will default to NEW INVOICE- if not, choose
  invoice in toolbar and slide down to NEW
• Choose PAYER (who is paying for this service)
• DO NOT CHANGE THE PAYEE IT SHOULD BE YOUR
  LOCATION
• Type in the patients last name and first name
  and click search
• choose the appropriate name by clicking on the
  name directly
• A new invoice sheet will open
• Choose the service provider from the pull down
  list of doctors
• Choose the appropriate service for which the
  payer is paying for from the service input list
• A description will appear along with a fee. This
  may be edited if needed.
• The price will appear with a balance owing
• Click on SAVE AND ISSUE

24
Incomplete Claims

1. Go to BILLING module
2. Under INVOICES in the toolbar, choose BILLING
   SHEET, then SCHEDULE
3. Choose the first schedule name in the drop down
   box (Do not choose ALL)
4. Enter in the FROM and TO dates (no more than 14
   days at a time)
5. Click LIST TO BILL grey tab
6. Any claims that show up have not been billed for
   some reason or other
7. Bill the claims and submit them
8. Repeat steps 3-7 for every schedule name in the
   drop down box
9. After completing step 8, change the dates in the
   FROM and TO fields and start over from step 3
   until you have finished all incomplete claims to
   the current day.

25
Resubmitting Claims in Error

• Go to BILLING module
• Choose EDI in toolbar, then choose CLAIMS IN
  ERROR.
• All claims that appear have been rejected for
  some reason
• Clicking on the name will open up the claim and
  there will be a description on the top of the
  screen explaining why this claim was rejected.
• Correct the information in the claim and click
  SAVE, this will resubmit the claim.

26
Resubmitting Claims by Manual Review

• Applies to claims that have been paid by the
  Ministry to a physician in error for various
  reasons.
• There are times when a claim can be resubmitted
  electronically instead of using the manual review
  form.
• Other times, a Remittance Advice Inquiry
  (Manual Review) form must be completed.

27
When to Resubmit Electronically

• When a claim has been paid but is missing a
  component.
• Example 1 Procedure code was omitted when
  original claim was submitted.
• Example 2 Keying error such as S007A instead
  of A007A
• - Open claim, click on Manual Review check box,
  add omitted/incorrect information, click
  Re-submit claim.

28
When to Re-Submit using Manual Review Form

• Any claim submitted that was paid by the Ministry
  in error for reasons other than simple omissions.
• Example 1 Claim paid to wrong physician
• Example 2 Claims submitted for wrong
  patient
• - Fill in Remittance Advice Inquiry form, make
  a photocopy for tracking purposes, mail original
  to MOH. The form is available online to
  download. It can also be ordered from the MOH
  and will arrive as a 3 part carbon form.

29
Printing Monthly Invoices

1. Go to REPORTS module
2. Click on Custom in toolbar
3. Choose the appropriate Location in pull down menu
4. Choose the appropriate month in pull down menu
5. Choose the appropriate physician in pull down
   menu
6. Click print invoice or print detailed invoice

30
Printing Remittance Advice

1. Click on BILLING module
2. Point to EDI in toolbar
3. Click on RETURN DOCUMENTS
4. Choose appropriate physician in pull down menu
5. Click search
6. Click on appropriate statement date
7. Click on OPTIONS box in top right corner
8. Choose print detailed remittance advice

31
3 Parts to the Remittance Advice

• 1. Remittance Advice
• This is a detailed report of all claims submitted
  for a physician by Appletree Medical Group.
• It is sorted by Location, Patient, Service Date,
  Fee Code, Paid Amount, and Ministry Code
• Describes any changes made by the ministry
  regarding a submitted claim

32
3 Parts to RA (cont)

• 2. Accounting Transaction
• Report of different transactions that were paid
  out by the MOH.
• Examples are
• Retro Payments
• Comp. Care Capitation
• Reciprocal Payments
• Comp. Care Reconciliation

33
3 Parts to RA (cont)

• 3. Message Facility
• Report of what the physician billed in the last
  fiscal year (April 01- March 31)
• Billed in the current year
• Bank Deposit of current billing cycle
• FHG incentive/Bonus/Premium Report
• Explanation of Ministry Codes

34
FHG Manager Responsibility

• Ensure the use of the Tracking Sheet for staff
  bonuses
• Document all bonuses for payroll
• Compare the amount of Q200/Q013 codes billed to
  the bonuses being paid
• Review forms twice a week
• Patient signature
• Date
• Pt declaration for self and/or child
• MD date

35
FHG Responsibility (cont)

• Stamp each form with MD stamp
• If rostering for another physician not working in
  your center, send reviewed forms to the
  appropriate location to be stamped and processed
• Count how many forms for each MD- only 100 forms
  can be submitted per envelope
• Fill in FHG Batch Header

36
FHG Responsibility (cont)

• Mail in the Ministry Envelopes
• Once ministry reports are received at the center,
  de-roster any patients that were de-rostered by
  the ministry (document in patient notes and on
  form to file in chart)
• Correct and re-send any forms that had been
  rejected due to errors
• Order supplies Enrollment forms, envelopes,
  batch headers