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Medical Claims Processing: Your Account Managers Are Your Best Resource

At some point, you may need to contact Apex EDI to ask a question or troubleshoot an issue. One of the major components of our business philosophy is the support we give our clients. Your account manager is your best resource for help getting your claims successfully submitted.

We recently learned that optometry clients had discovered claims were failing after treating post-operative patients. Nothing concerns us more than our providers not getting paid. It is the reason we exist. As soon as we discovered the issue we jumped right in to figure this out and to create a solution.

It was our account management team that discovered the problem and put together a communication to make sure all parties affected learned how to avoid it in the future. Let's take a look at this case study as one way we help resolve your concerns.

Case Study

What to know
There are two dates that must be on a claim in order for the claim to process correctly.

1. The Assumed date is usually the day after surgery and is the date that the office “assumed” care of the patient.
2. The Relinquish date is usually 90 days after the assumed date and is the date that the office ended or “relinquished” care of the patient.

Procedure Dates
Assumed and relinquished dates should normally be 90 days apart exactly. An easy way to do it is to count ahead 13 weeks from the assumed care date and then subtract one day. If surgery was performed on a Wednesday, you look forward 13 Wednesdays from the assumed date and go to the previous day (Tuesday) as your relinquished date.

Claim Format
The proper way to bill post-op claims through Apex is by using box 19, “Reserved for Local Use”. Due to the nature of the electronic claim form, the format in which we receive the post-op data is very crucial. Please use the following template when billing your post op claims.

Post op dd/mm/yyyy to dd/mm/yyyy

For Example
Post op 03/12/2011 to 06/10/2011
The first date is the assumed date and the second is the relinquished date.

Verify Post op Claim Format & Claim Date
Claims can be verified by checking for the assumed and relinquished dates on the claim.

Look for the following segments:

DTP*090*D8*20110325—Assumed date
DTP*091*D8*20110622—Relinquished date

This is just one example of how our highly trained account managers can help you successfully submit claims that get paid. Below are a few more examples of how Apex EDI and our technology and account managers can help.

Reports

Reports from insurance companies provide a status of your claims including claim rejections. In many cases, the rejections provided in the reports Apex provides from insurance companies are the only notice of rejection that you will receive. In addition, reports from insurance companies are generally delivered in 24-48 hours from the time claims are submitted, so the quick response allows you to act quickly to ensure a claim’s payment is not delayed. It is important to know that not all insurance companies provide reports. If the insurance company does not provide electronic status reports, you will receive rejection notices by mail. Apex attempts to make the reports more reader friendly and understandable, but if you ever don’t understand a report, please call your Apex Account Manager for assistance.

Rejection

If you receive a rejection notice from an insurance company and you are not sure why, you should first call the insurance company to get clarification on the rejection reason. If you find the problem is something you can fix, such as an incorrect subscriber ID or birth date, then you need to fix the claim in your practice management software and resubmit it electronically. If the insurance company offers little or no help or their explanation is confusing and leaves you still wondering what to do, you should contact your Apex account manager who will assist you in understanding and fixing the problem.

Account Managers

At Apex we have assigned account managers by region. This allows our account managers to become expert at dealing with the issues that prevent or delay payments of your insurance claims. Also, by assigning an account manager, you have direct access to an account manager that will have maximum availability to assist you. However, any account manager can assist you.

If you ever need any help, please contact your account manager so that we can help you find a way to solve your issue.

About Apex EDI

Apex EDI is a leading healthcare claims clearinghouse for medical and dental professionals. Apex EDI serves thousands of physicians, dentists, and other medical providers nationwide with its Apex OneTouch® solution. The OneTouch® solution is a Web-based electronic claims reimbursement system that increases productivity and profitability while facilitating fast payment of insurance claims and providing additional reporting and analysis. Founded in 1995, Apex EDI is based in American Fork, Utah.

Posted in: Medical Claims Processing

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