Filling Out Insurance Claim Forms

Now another form we're going to look at is an Insurance Invoice Example (see Required Written Materials), you will give to the client to send with their initial insurance claim form. When you have the client file the claim, they generally will only have to complete the insurance claim form online or on hard copy they mail to the company.  They generally only do this once, then you or the client will just file online or send invoices to the insurance company after each session.  When looking at the invoice example, you will notice the detailed information you, the counselor, provide “From” and “Bill To”.  Then, the Date and Description provided, that includes the CPT code (see Behavioral Health Codes AMA) with a general diagnosis.  Other than the billed cost, that’s usually all that is needed on your invoice.

The second form is an example of an insurance claim form.  Please, never use this form, it only serves as an example in understanding how to fill out a claim form.  Open the Health Insurance Claim Form.  Now you're going to notice that there are instructions for filing on a second page, have the client read them closely and make sure they've got all the information they need. Because the claim form generally says, “Note: We cannot process your claim without all the information listed above. If any of the above items are missing, please contact the provider of the service(s) to obtain the information.” What that means is, I've seen them set for months in insurance companies. They lose them underneath a stack of files. They don't get back to you. The client wonders what's going on. So, if this information isn't on here, I can tell you, point blank, they're not going to process it, and they're not going to worry a whole bunch about processing it. They're going to wait for you to call.  Probably if the client is paying for the cost of the sessions, but if they're on a low cash basis, then they're looking for this payment so they can continue to counsel with you. So, it's important that you facilitate this whole thing being done correctly.

Most insurance customer service operators will say, “Complete one form for each member of the family.” So, if you have a mother, father and child, you're going to fill out three of these things, and for each illness or accident, have the primary attending physician complete the physician's statement. In essence, it’s going to be up to you to complete the insurance forms and all correspondence, then close itemized bills once you file this first form.  Then the invoice that you send them and send to the client after each session.

Now if we look at the top left hand corner of the Member Submitted Reimbursement Request Form, then at the bottom of the form, it must be completed on all claims and to be completed and signed. If they don't sign it, they won't process it, even if everything else is right. A lot of times, people will mail the completed form, and they have not signed it, so offer to look their completed form over with them, scan it for your own records. 

Now notice, the first line says the Identification and Group Number, then the Subscriber’s Last and First Name, with Birthdate. You have to ask them for a copy of their insurance card. They may have a card they have to look at the date of birth, kind of be specific. These are pretty common things they ask for, regarding the Patient’s Name, Address and Birthdate. Then whether the patient has other insurance coverage, when it is a spouse employed is a second insurance company that they can bill to.  If they can reduce their cost, they're going to do it. If you say “Yes” to the secondary insurance, then they're going to want to know the street address of the employer, things like that.

Next the form will want the provider’s name (your name) and address for your office. Then Other Coverage Information related to an injury or auto accident, which I usually put not applicable (N/A).  I put N/A in every place where something doesn't apply, or someone's likely to say they didn't fill this out and shoot it back to you. So don't leave anything blank. Put in N/A, wherever you need the date of accident or beginning of sickness. Then there are some questions regarding other insurance coverage, again where I either check no or N/A.  Then be sure the client/subscriber signs the form. So, you have the signature of a subscriber or spouse.  Now that's the first side of this thing, and it's pretty common. You'll find variations in what the form looks like and all this kind of stuff, but it's still the basic information.  

These questions are pretty standard, typical of what you're going to find, but this thing comes in sections or parts, so we're going to look at page 2, “How to submit your claim:”.  You will see reminders about filing this form for the client.  Also, you can attach a brief summary of case notes for each session.  Then, the information to be included on the client’s bill/invoice that you provide. Keep in mind the insurance company will not reimburse for marital or couples counseling.  If they're receiving marital counseling, I can tell you up front, they won't pay for marital counseling, so you can't say that you have to give a diagnosis. Yet, if they are coming for couples counseling, there may also be anxiety and stress, which can be filed as an individual session. I'll explain that to you later.  

On the bill/invoice, they're looking for here will be either a DSM 5-TR, which is Diagnostic Statistical Manual code, or an international code for diagnosis (ICD on the ICD Behavioral Health Codes form).  So, when you're looking at this part of the bill/invoice, this is the most important part you need to get by purchase or have available to you, the Diagnostic Statistical Manual 5–TR. In general, there are a few things you need to know.