The good news?

With the right Medicaid billing steps, it soon becomes routine.

Whether you run a solo office, work in a group practice, or just joined a Medicaid plan, you need a clear roadmap for the entire process.

This guide from BellMedEx gives you exactly that.

What Is Medicaid?

Medicaid is a health program jointly run by the federal and state governments in the U.S. It now covers more than 80 million people, including:

• Children
• Pregnant women
• People with disabilities
• Low-income adults
• Seniors who also receive Medicare (known as “dual eligibles”)

Why Should Healthcare Providers Treat Medicaid Patients?

Many providers worry that Medicaid pays less than private insurance or Medicare. Still, three major reasons make it worth considering:

Large patient pool – Medicaid covers a fast-growing segment of the population, especially in underserved areas.

State-level incentives – Some states offer extra perks like value-based payments or higher rates for specific specialties.

Community impact – You’re helping some of the most vulnerable people. That service brings lasting value to your community.

Here’s How to Bill Medicaid as a Provider:

Here’s a full breakdown of how to bill Medicaid successfully, from credentialing to getting reimbursed.

Step #1 – Enroll as a Medicaid Provider

You can’t send a single reimbursement claim to Medicaid until the program adds you to its roster. Therefore, your first job is getting on that list.

Think of it like joining the payroll before payday.

a). Find your state’s portal

Every state runs its own enrollment portal, and they all live on official .gov pages. A quick search for “[Your State] Medicaid provider enrollment” on Google will land you on the right link.

For example:

• In Texas, you’ll use TMHP (Texas Medicaid & Healthcare Partnership).
• In California, it’s PAVE (Provider Application and Validation for Enrollment).

If the web address doesn’t end in .gov or belong to a well-known state partner, then don’t trust it.

b). Collect the paperwork before you log in

Have these items ready before you start the Medicaid provider enrollment form:

c). Complete the online application

• Log in or create an account on your state’s portal.
• Follow each screen. Upload documents as asked.

If a field stumps you, most portals have a help line or live chat—so use it. You can also call the state’s Medicaid provider relations office, as that team’s entire job is guiding newbies like you through enrollment.

d). Let the state verify you

After you click Submit, the state reviews your file. This “Medicaid credentialing” step checks licenses and other data.

• Time frame is usually between 30 to 90 days.
• Faster for solo providers.
• Slower if you enroll a new group practice.

Once approved, you’re ready to send Medicaid claims and get paid as a healthcare provider.

Step #2 – Verify Patient Eligibility Before Each Visit

Eligibility verification simply means you confirm, ahead of time, that Medicaid still covers your patient and the service you plan to provide. A quick check spares you from most “patient not eligible” denials.

a). First, pick the method that fits your day:

• State Medicaid portal: Log in, type the patient’s Medicaid ID or birth date, and you get an instant “yes” or “no.”
• EHR or clearinghouse tool: Many systems ping Medicaid in real time. If coverage has lapsed, you’ll see a pop-up before the patient arrives.
• Medicaid helpline: A phone call takes longer, yet it helps when the portal is down or the data looks odd.

b). When you run the check, look for four things:

1. Confirm active coverage for today. Benefits can end quickly if a patient’s income changes or renewal paperwork is delayed.
2. Review service limits. Office visits are usually covered in most states, but extras—such as dental, vision, or chiropractic care—may have caps or require prior approval.
3. Check for a managed care plan. Many Medicaid members belong to an MCO. If you see “Molina,” “UnitedHealthcare Community Plan,” or another HMO name, send the bill to that plan—not directly to the state.
4. Look for other insurance. Third-party liability (TPL) means the patient has private insurance too. Medicaid pays last, so you must bill the other plan first, even if it only covers part of the charge.

Step #3 – Confirm That Medicaid Covers the Service

You have your Medicaid ID. You’ve checked the patient’s eligibility. One last check keeps your claim safe: make sure the service itself is on your state’s covered list.

When we say “make sure the service is on your state’s covered list,” we mean this: look up the exact CPT or HCPCS code for the visit, test, or procedure you plan to bill. If that code isn’t shown as covered in your state’s Medicaid fee schedule—or if it needs prior approval—you risk a denial.

Here’s how to see what Medicaid will pay?

a). Open your state’s fee schedule

Search for “Your State Medicaid fee schedule 2025.” Look for a PDF or spreadsheet on a .gov site.

b). Scan the CPT or HCPCS codes you plan to use

The schedule shows:

• Whether the code is covered
• The dollar amount Medicaid pays
• Any limits, such as age caps or visit counts
• Whether prior authorization is required

Example: North Carolina allows up to 30 physical therapy visits a year. Another state might allow only 15—or none, unless the patient is under 21.

c). Check plan bulletins for updates

States post monthly or quarterly alerts. A code that paid last year may need approval today.

d). Call the authorization desk when in doubt

A five-minute call beats a denied claim.

Step #4 – Secure Prior Authorization When It Counts

You have the patient’s Medicaid card on file, you know the service is on the covered list, and you’re ready to book the test.

Great…

but hold on a moment!

Some services need prior authorization (PA) before you provide them. Getting that green light is the difference between a paid claim and a painful write-off.

➜ Spot the usual PA suspects

As a rule of thumb, if a service is pricey, ongoing, or ordered by a specialist, plan on requesting a PA:

• High-cost imaging: MRI, CT, PET
• Elective surgeries: tonsillectomy, joint replacement, bariatric procedures
• Therapy past routine limits: mental-health counseling, speech, PT, OT
• Durable medical equipment (DME): power wheelchairs, hospital beds
• Ongoing home-health or skilled-nursing visits

Quick example:

Your patient with chronic knee pain clearly needs an MRI. You open the Medicaid HMO’s PA list and, sure enough, the scan needs approval. Rather than gamble on reimbursement, you pause, submit the request, and wait for the go-ahead.

➜ A simple roadmap for requesting PA

a). Choose the right portal

Every state—or Medicaid HMO—runs its own PA system. Some accept secure online forms; others still rely on fax. Therefore, you need to pick the path the healthcare payer prefers.

• Fill in the nuts and bolts
• CPT or HCPCS code for the service
• ICD-10 code that backs up the medical need
• Provider and facility info
• Target date of service

b). Attach proof of need

Your clinical notes, past imaging, lab results, or a referring specialist’s letter strengthen the request. Think of this bundle as answering the question, “Why does this patient need this service right now?”

c). Send, then track

Most plans give a decision within a few business days, sometimes sooner if you flag the case as urgent. Log the submission date and reference number so no one has to guess where the request stands.

d). After you hear back

• Approved. You’re free to schedule the service. Save the approval letter or confirmation number in the chart and billing file.
• Denied. Read the reason line by line. Many denials stem from missing paperwork or the wrong diagnosis code, both fixable on appeal.
• Need more info. Plans may ask for clearer notes or an extra test result. Provide what they need and resubmit; no need to start from scratch.

Step #5 – Submit Your Medicaid Claim

You have checked the patient’s coverage, confirmed the service is allowed, and grabbed any prior approval you need. Nice work. Now let’s make sure you actually get paid.

a). Pick the right claim form

• CMS-1500. Use this for office visits, shots, labs, or any other professional service.
• UB-04. Use this when you bill as a facility—hospital stays, outpatient surgery, skilled-nursing care.

Even if you hit “submit” inside your EHR, these forms sit behind the scenes. The software fills them in for you.

b). Drop in the correct codes

• ICD-10 tells Medicaid why you treated the patient.
• CPT or HCPCS show what you did.
• Modifiers add detail. For a flu shot given during a check-up, list:
  • 99213 – office visit
  • 90686 – flu vaccine
  • 90471 – vaccine administration
  • -25 on 99213 to prove the visit was separate from the shot.

c). Add a Place-of-Service (POS) code

This code shows where the care happened. A few you’ll use often:

• 11 – office
• 22 – outpatient hospital
• 12 – home
• 31 – skilled-nursing facility

Check this code twice. A wrong POS is a top reason claims bounce back.

d). List the right NPI numbers

• The rendering provider NPI must match the person who gave the care and must match the NPI on file with Medicaid.
• If you bill as a group, add the group NPI too.

e). Choose how to send the claim

• Through your EHR or practice management software. Fastest. The system fills the claim and flags missing data before you hit send.
• Through a clearinghouse. Acts like a mailroom: it scrubs errors, then routes the claim to the correct Medicaid payer.
• Direct upload to the state portal. Handy if you bill only now and then or do not have an EHR.

f). Track the claim afterward

Submitting is only half the job. Log back in a few days later and look at:

• Status – pending, paid, or denied
• Payment amount – matches your fee schedule?
• Remittance advice (RA) – explains reductions or denials

Catching a denial early often means a quick fix rather than a drawn-out appeal.

Step #6 – Track Each Claim and Match Every Dollar

Submitting the claim is only halftime. To get paid in full, you still need to watch the claim move through the system and confirm the deposit hits your account. A little follow-through here prevents big revenue leaks later.

a). How to keep eyes on your claims

➜ State Medicaid portal

Log in, search by patient or claim number, and read the status line: submitted, pending, paid, or denied.

➜ Clearinghouse dashboard

Tools like Availity or Office Ally show real-time updates—when Medicaid received the claim, whether it passed edits, and when it heads to payment.

➜ Remittance advice (RA) or EOB

This document tells you what was paid, reduced, or refused and why. Review it line by line as soon as it arrives.

b). Denials that pop up most

• Bad patient data – a wrong Medicaid ID or mistyped birth date can sink the claim.
• Coverage gap – the patient was not eligible on the service date.
• NPI or Tax ID mismatch – your claim info does not match Medicaid’s enrollment file.
• Missing prior authorization – the service needed approval, but no PA number was on the claim.

c). Reconciling payments the smart way

• Match every deposit to the specific claim in your billing system.
• Flag under-payments at once—was it a contract adjustment or an avoidable denial?
• If you need to appeal, move fast; many Medicaid programs close the window after 90 days.

Step #7 – Fix and Resubmit Denied or Rejected Claims

A denial is normal. It just means something on the claim needs a quick edit. Most states let you correct and resend—as long as you do it within their time limit (often 90–180 days from the date of service).

a). Read the denial note

Look at the Remittance Advice, EOB, or your portal. Find the short code that tells you what went wrong.

• CO-16 – missing or wrong info
• PR-49 – patient not eligible that day
• CO-96 – wrong code or modifier
• CO-109 – service not covered

b). Fix the problem

• Correct any typos in the patient name, Medicaid ID, or date of birth.
• Add the right modifier (-25, -59, etc.).
• Swap in the correct diagnosis or procedure code.
• Include the PA number if you left it off.

If the denial is about medical need, attach your notes or test results to show why the service was required.

c). Resend the claim

Use the same route you used before—portal, clearinghouse, or EHR. Mark it as a corrected claim if your state asks for that. Some states want the original claim number or a resubmission code (often “7” for a replacement claim).

d). Watch the deadline

Send the fix before the timely-filing window closes. If you are already past it, file an appeal right away and explain why you could not meet the deadline (for example, a system outage or mail delay).

e). Keep a simple denial log

Write down each denial in a list:

• Patient name and service date
• Denial reason
• Date you fixed it
• Date you resent it
• Final result

Seeing the patterns helps you prevent the same mistake next time.

The Medicare system can be daunting at first. However, once you master the enrollment process and billing requirements, you’ll find it manageable. This step-by-step guide helps you learn how to bill Medicare as a provider, from Medicare claim submission to getting paid.

Many new providers struggle with Medicare’s documentation requirements and coding standards. Others face delays because they miss enrollment deadlines or submit incomplete applications. Let us share practical steps to avoid these common pitfalls while maximizing your reimbursements.

How to Bill Medicare as a Provider (Complete Guide)

Medicare billing process for providers requires three essentials:

• Proper enrollment to Medicare
• Accurate claim submission
• And ongoing compliance.

To bill Medicare as a provider, you must obtain an NPI number and enroll through the Provider Enrollment, Chain, and Ownership System (PECOS). Next, you’ll verify patient eligibility and gather required documentation before submitting claims to your Medicare Administrative Contractor (MAC). Finally, you must maintain accurate records and update your enrollment information as needed.

The entire process follows a structured workflow designed to protect both providers and beneficiaries. Medicare uses standardized systems like the resource-based relative value scale (RBRVS) to determine payments. Your MAC processes claims and handles communications throughout the billing cycle. Success depends on understanding each step and following established guidelines consistently.

What is Medicare? And What Does Medicare Billing Mean for Providers?

Medicare serves as America’s federal health insurance program for adults aged 65 and older. The program also covers younger individuals with specific disabilities or permanent kidney failure. The Centers for Medicare and Medicaid Services (CMS) manages this vast system that processes billions of claims annually.

Medicare program divides into three main parts that affect your Medical billing strategy.

For providers, Medicare billing means following federal regulations while serving eligible beneficiaries. You must determine which Medicare part covers each service you provide. Some patients only qualify for certain coverage types, which affects your billing strategy.

Medicare may act as a secondary payer when patients have other insurance coverage.

Understanding Medicare’s structure helps you navigate billing requirements more effectively. Each part has different rules, payment schedules, and documentation needs. Your billing staff must recognize these differences to submit accurate claims and avoid denials.

How to Bill Medicare as a Provider (Step-by-Step)

Successfully billing Medicare requires following a systematic approach from enrollment through payment reconciliation. The process involves multiple steps that build upon each other to ensure compliance and maximize Medicare reimbursement.

Here are the nine essential steps every provider must master:

1. Obtain an NPI Number
2. Enroll in Medicare
3. Verify Enrollment and Maintain Compliance
4. Verify Patient Eligibility and Coverage 
5. Gather Required Documentation
6. Submit Claims to Medicare
7. Respond to MAC Communications and Track Claims
8. Receive Payment and Reconcile Accounts
9. Maintain Records and Compliance

Let us dive a little deeper into these steps to billing Medicare as a healthcare provider.

1. Obtain an NPI Number

Your National Provider Identifier (NPI) serves as your unique healthcare identifier across all transactions. This 10-digit number links all your Medicare billing activities to your practice or facility. Without an NPI, you cannot submit claims or receive payments from Medicare.

Apply for your NPI through the National Plan and Provider Enumeration System (NPPES) website. The application process requires basic information about your practice, including your name, address, and taxonomy code.

Note: Individual providers and healthcare organizations each need separate NPI numbers.

The NPPES system typically processes applications within 10 business days. You’ll receive your NPI via email once approved. Keep this number confidential and use it consistently across all Medicare transactions. Never share your NPI with unauthorized individuals or organizations.

Some providers already have NPI numbers from other insurance billing. You can use the same NPI for Medicare if it’s still active and accurate. Verify your existing NPI information through the NPPES registry before proceeding to Medicare enrollment.

2. Enroll in Medicare

Medicare enrollment establishes your eligibility to bill the program for covered services. The process varies depending on whether you’re an individual provider or institutional facility. Individual physicians typically complete the CMS-855I form, while groups use CMS-855B forms.

Access the enrollment system through PECOS, Medicare’s online platform for provider registration. Create your account using your NPI number and basic practice information. The system guides you through each section of the enrollment application.

Institutional providers face additional requirements during enrollment. Hospitals, skilled nursing facilities, and similar organizations must pay application fees. These fees vary by provider type and are updated annually on the PECOS website.

Prepare supporting documentation before starting your application. You’ll need copies of your professional license, malpractice insurance, and curriculum vitae. Some provider types require additional certifications or accreditations. Having these documents ready speeds up the enrollment process.

3. Verify Enrollment and Maintain Compliance

Your Medicare Administrative Contractor (MAC) reviews your enrollment application and may request additional information. Respond promptly to any MAC communications to avoid processing delays. The review process can take several weeks depending on your provider type and application completeness.

Once enrolled, you must keep your information current in the PECOS system. Report ownership changes, legal actions, or address updates within 30 days. Other enrollment changes must be reported within 90 days. Failure to maintain current information can result in payment delays or enrollment termination.

Institutional providers may undergo site visits or surveys during the enrollment process. Your CMS Location and State Agency coordinates these evaluations. Prepare your facility for inspection and ensure all required documentation is readily available.

Monitor your enrollment status regularly through PECOS. The system shows your current status and any pending actions. Address any issues immediately to maintain uninterrupted billing privileges. Set calendar reminders for important deadlines and renewal dates.

4. Verify Patient Eligibility and Coverage

Patient eligibility verification prevents claim denials and ensures proper billing. Check each patient’s Medicare status before providing services. Use your MAC’s portal or eligibility verification tools to confirm coverage details.

Determine whether Medicare serves as the primary or secondary payer for each patient. Other insurance coverage may take precedence over Medicare in certain situations. Workers’ compensation, employer group health plans, and auto insurance often pay before Medicare.

Collect comprehensive insurance information from every patient. Use the CMS Questionnaire or similar forms to gather employment and coverage details. Ask about spouse’s insurance, recent accidents, and work-related injuries. This information helps identify other potential payers.

Document your eligibility verification efforts in the patient’s record. Note the date, method, and results of your verification. This documentation supports your billing decisions and helps during audits or appeals. Update eligibility information if the patient’s circumstances change.

5. Gather Required Documentation

Accurate documentation forms the foundation of successful Medicare billing. Collect all necessary information before submitting claims to avoid delays or rejections. Your documentation must support the medical necessity of services provided.

Start with basic patient demographics including name, date of birth, and Medicare Beneficiary Identifier (MBI). Verify the patient’s address and contact information. Ensure the MBI matches exactly with Medicare’s records to prevent processing errors.

Select appropriate diagnosis codes using the current ICD-10 system. Choose codes that accurately reflect the patient’s condition and support the services provided. Use the most specific code available and include secondary diagnoses when relevant.

Identify correct procedure codes using CPT or HCPCS Level II codes. Match procedures to appropriate diagnosis codes to demonstrate medical necessity. Apply modifiers when required to clarify services or indicate special circumstances. Review coding guidelines regularly!

6. Submit Claims to Medicare

Electronic claim submission offers the fastest and most reliable method for Medicare billing. Use HIPAA-compliant systems that meet federal privacy requirements. Most practice management systems include Medicare billing capabilities.

Submit claims through your MAC using approved Electronic Data Interchange (EDI) formats. The standard format for professional claims is the 837P transaction. Institutional claims use the 837I format. Ensure your medical billing system supports these formats.

Paper claims serve as a backup option when electronic submission isn’t possible. Use the CMS-1500 form for professional services or the UB-04 form for institutional services. Complete all required fields and include supporting documentation when necessary.

Medicare Advantage patients require different claim submission procedures. Send these claims directly to the patient’s specific plan administrator, not to traditional Medicare. Each Medicare Advantage plan has its own submission requirements and contact information.

7. Respond to MAC Communications and Track Claims

Your MAC processes all Medicare claims and manages communications throughout the billing cycle. Monitor your submissions regularly and respond promptly to any requests for additional information. Delays in responding can result in claim denials.

Track claim status through your MAC’s provider portal or electronic systems. Claims typically process within 14-30 days depending on complexity. Follow up on any claims that exceed normal processing times.

Address claim rejections immediately by reviewing error messages and correcting problems. Common rejection reasons include invalid patient information, coding errors, or missing documentation. Resubmit corrected claims as soon as possible.

Appeal denied claims when you believe Medicare’s decision is incorrect. Submit additional documentation or clarification to support your position. Follow the appeals process outlined by your MAC and meet all required deadlines.

8. Receive Payment and Reconcile Accounts

Medicare payments arrive via electronic funds transfer to your designated bank account. Payment amounts reflect the Medicare fee schedule minus any applicable deductibles or coinsurance. Reconcile payments against your submitted claims to identify any discrepancies.

Review your Medicare Summary Notice (MSN) or Electronic Remittance Advice (ERA) for payment details. These documents explain what Medicare paid, what the patient owes, and any claim adjustments. Use this information to bill patients for their portion of costs.

Handle patient billing carefully to comply with Medicare regulations. You cannot bill patients for services that Medicare doesn’t cover unless you provide proper advance notice. Use Advance Beneficiary Notices (ABNs) when services may not be covered.

Track your accounts receivable to ensure timely payment collection. Follow up on unpaid claims and patient balances according to your practice’s policies. Maintain detailed records of all collection efforts for audit purposes.

Tip: Some visits can be billed incident-to and pay the full doctor rate even if a nurse practitioner saw the patient. Learn the rules here → [Medicare incident-to billing guide]

9. Maintain Records and Compliance

Medicare requires providers to maintain comprehensive records for audit and compliance purposes. Keep all billing documentation, patient records, and correspondence for at least five years. Some states have longer retention requirements.

Update your PECOS enrollment information whenever changes occur. Report new locations, ownership changes, or changes in services provided. Keep your contact information current to ensure you receive important Medicare communications.

Participate in Medicare audit requests promptly and thoroughly. Provide requested documentation within specified timeframes. Maintain organized records that allow quick retrieval of information during audits.

Stay informed about Medicare policy changes and updates. Subscribe to your MAC’s newsletters and attend provider education sessions. Changes in coverage, coding, or billing requirements can affect your reimbursement if not implemented properly.

Medicare Provider Billing Guidelines

Medicare billing guidelines are a set of rules that providers must follow when submitting claims for reimbursement. Following these guidelines helps providers submit claims accurately. This also protects healthcare providers and beneficiaries.

Key Medicare provider billing guidelines include:

• Document medical necessity for all services in patient records
• Use accurate CPT, HCPCS, and ICD-10 codes for all procedures and diagnoses
• Apply modifiers correctly to indicate service variations or special circumstances
• Submit claims within 12 months of service date
• Determine primary vs. secondary payer status for each patient
• Bundle services appropriately and avoid improper unbundling
• Accept Medicare’s approved amounts when participating in the program
• Maintain accurate patient insurance and employment information
• Coordinate benefits with other insurance carriers when applicable
• Respond promptly to MAC requests for additional information
• Keep detailed records for audit and compliance purposes
• Update enrollment information within required timeframes
• Follow appeals procedures for denied claims
• Bill patients appropriately for non-covered services with proper notices
• Use electronic submission methods when possible
• Protect patient information according to HIPAA requirements

Common Medicare Medical Billing Questions

Let us answer some of the most common Medicare billing questions for providers.

1. What is the Medicare billing process?

The Medicare billing process involves submitting claims electronically to your assigned Medicare Administrative Contractor (MAC) for covered services. You must first enroll in Medicare, obtain an NPI number, and verify patient eligibility before providing services.

After treatment, you code the services using appropriate CPT and ICD-10 codes and submit the claim within one year. Your MAC reviews the claim for accuracy and compliance with Medicare guidelines. They may request additional documentation or clarification before processing payment. Once approved, Medicare pays 80% of the approved amount for Part B services. Patients remain responsible for deductibles and coinsurance.

2. What providers can bill Medicare?

Medicare accepts claims from a wide range of healthcare providers including physicians, nurse practitioners, physician assistants, and clinical specialists. Hospitals, skilled nursing facilities, home health agencies, and hospice organizations also qualify for Medicare billing.

Other eligible providers include physical therapists, occupational therapists, speech-language pathologists, and clinical social workers.

Suppliers such as ambulance services, durable medical equipment companies, and independent diagnostic testing facilities can also bill Medicare. Healthcare providers must enroll in the Medicare program and meet requirements established by CMS. Enrollment requirements vary by provider type and may include licensing, accreditation, or certification standards.

3. Is provider based billing only for Medicare?

Provider-based billing extends beyond Medicare to include Medicaid and some Medicare Advantage plans. This billing method separates professional and facility charges for services provided in hospital-based outpatient clinics or departments. CMS requires this approach for government programs. But some insurance companies also use provider-based billing models.

The requirement affects facilities that have relationships with hospitals and bills under the hospital’s NPI number. Private insurance plans may combine professional and facility charges into single bills, but Medicare and Medicaid maintain separate billing requirements.

4. Are providers required to bill Medicare?

Most providers must submit claims to Medicare for covered services provided to Medicare beneficiaries, regardless of their participation status. Participating providers agree to accept Medicare’s approved amounts and must file claims for all covered services. Non-participating providers can accept assignments on a case-by-case basis but must still submit claims.

Providers can opt out of Medicare entirely by entering into private contracts with patients. In this arrangement, providers cannot bill Medicare and patients pay entirely out-of-pocket. Certain exceptions exist for small providers, roster billing, and demonstration projects. But the general rule requires claim submission for covered services.

5. How to Bill Medicare Electronically?

Electronic Medicare billing uses HIPAA-compliant systems to submit claims through Electronic Data Interchange (EDI) transactions. Providers transmit claims to their MAC using direct data entry screens or practice management software. The system automatically checks claims for errors and returns rejected submissions for correction before final processing.

Most healthcare facilities use clearinghouses or billing services that handle electronic transmission. These intermediaries convert claims into proper EDI formats and manage the submission process. Electronic billing reduces processing time, minimizes errors, and provides faster payment compared to paper submissions.

6. What Payment Will I Receive From Medicare?

Medicare payments follow the resource-based relative value scale (RBRVS) system that calculates reimbursement based on resources required for specific services. Payment amounts vary by geographic location, provider specialty, and service complexity. The Medicare Physician Fee Schedule provides specific payment rates updated annually.

Medicare pays 80% of approved amounts for Part B services, with patients responsible for remaining costs. Part A payments vary by service type and may include deductibles or coinsurance. Providers who accept assignments agree to Medicare’s approved amounts as full payment. Non-participating providers can charge limited additional amounts above Medicare’s rates.

Moving on, getting cardiography coding right is essential because it affects everything. Be it patient bills, insurance coverage or the overall quality of healthcare revenue cycle management.

What exactly is non-surgical cardiography?

It refers to heart-imaging or heart-monitoring tests done without an incision. These tests help doctors see how the heart is working without a surgical procedure. Furthermore, they lay a foundation in diagnosing or managing several heart conditions.

In this blog, we’ll go over some common non-surgical cardiography procedures you might see in cardiology system coding. Also, learning about these tests in advance makes coding easier and more accurate.

Before we dive into the non-invasive cardiology procedures, let’s have a quick look at the working of cardiology coding.

How Cardiology Coding Works?

Cardiology procedures are primarily coded using Current Procedural Terminology (CPT) codes in the U.S. Basically, these codes describe medical, surgical, and diagnostic services. And for international or inpatient coders, the ICD-10-PCS system may be used. But for most outpatient non-surgical cardiography, CPT is your go-to.

Non-Surgical Cardiography Procedures found in the Cardiovascular System Coding

Top Non-Surgical Cardiography Procedures & Common CPT Codes

Non-surgical cardiography procedures play a vital role in diagnosing and monitoring heart conditions. These tests are commonly used in cardiology practices, urgent care settings, and hospitals. 

Furthermore, it’s important to know how to choose the correct CPT and ICD-10-PCS codes for these tests. Because using the right codes helps make sure that billing is accurate and insurance payments aren’t delayed. 

Here is a list of the most common non-invasive heart tests, along with the codes used for outpatient (CPT) and inpatient (ICD-10-PCS) billing.

1). Electrocardiogram (ECG / EKG)

What it is: A quick, painless test that records the heart’s electrical activity using electrodes placed on the skin.

Why doctors order it: To detect arrhythmias, ischemia, and signs of a recent or ongoing heart attack.

CPT Codes:

• 93000 – Complete (includes both tracing and interpretation)
• 93005 – Tracing only
• 93010 – Interpretation only

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

2). Holter Monitor (24 to 48-Hour ECG)

What it is: A portable device that continuously records heart rhythms for 24–48 hours.

Why doctors order it: To identify irregular heartbeats that may not appear during a standard ECG.

CPT Codes:

• 93224 – Full service (global)
• 93225 – Device hookup and patient instructions
• 93226 – Technical recording and monitoring
• 93227 – Final interpretation and report

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

3). Event Monitor (Loop Recorder)

What it is: A wearable or implantable device that captures abnormal heart rhythms when activated by symptoms or automatically.

Why doctors order it: Used for long-term heart rhythm monitoring, especially in patients with fainting spells or dizziness.

CPT Codes:

• 93268 – External loop recorder (global)
• 93270 – Setup and education
• 93271 – Data recording and transmission

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

4). Transthoracic Echocardiogram (TTE)

What it is: A heart ultrasound using a probe on the chest wall.

Why doctors order it: To evaluate heart valves, muscle function, chamber size, and ejection fraction.

CPT Codes:

• 93306 – Complete echocardiogram with Doppler and color flow
• 93307 – Complete echocardiogram without Doppler
• 93308 – Limited or follow-up study

ICD-10-PCS: 

• B245ZZ3 – Ultrasonography of heart, transthoracic, real-time

5). Stress Tests (Exercise or Pharmacologic)

What it is: Measures heart response to stress from exercise or medication.

Why doctors order it: To detect ischemia or reduced blood flow in patients with symptoms like chest pain or shortness of breath.

CPT Codes:

• 93015 – Complete stress test with supervision, interpretation, and report
• 93016 – Supervision only
• 93017 – Tracing only
• 93018 – Interpretation and report only

6). Stress Echocardiography

What it is: Combines exercise (treadmill or bicycle) with echocardiography imaging.

Why doctors order it: To evaluate blood flow and heart wall movement under stress conditions.

CPT Codes:

• 93350 – Echocardiographic imaging during stress
• 93351 – Full package: stress echo with supervision, interpretation, and report

ICD-10-PCS: 

• B245ZZ3 – Transthoracic ultrasonography with stress (exercise or pharmacologic)

7). Dobutamine Stress Echocardiography

What it is: Uses the drug dobutamine to simulate exercise in patients who cannot physically exert themselves.

Why doctors order it: To assess cardiac function when exercise stress testing isn’t possible.

CPT Codes:

• 93350 – Stress echo imaging only
• 93351 – Stress echo with supervision and interpretation

ICD-10-PCS: 

• B245ZZ3 – Real-time ultrasound of heart under pharmacologic stress

8). Cardiac CT for Calcium Scoring

What it is: A non-contrast CT scan that measures calcium buildup in coronary arteries.

Why doctors order it: Risk assessment for coronary artery disease in patients with no symptoms.

CPT Code:

• 75571 – CT scan of heart without contrast (calcium scoring)

ICD-10-PCS: 

• B210YZZ – CT scan of heart without contrast

9). Cardiac CT Angiography (CCTA)

What it is: A CT scan with contrast that produces 3D images of coronary arteries.

Why doctors order it: Helps detect blockages, plaque buildup, or congenital heart defects.

CPT Codes:

• 75572 – CT with contrast for heart structure and function
• 75573 – CT with contrast for congenital heart disease
• 75574 – CT with contrast and 3D post-processing

ICD-10-PCS: 

• B2101ZZ – CT scan of heart with contrast

10). Cardiac MRI

What it is: A magnetic resonance scan providing highly detailed imaging of the heart.

Why doctors order it: Detects scarring, structural abnormalities, cardiomyopathies, and congenital heart defects.

CPT Codes: 

• 75557 – MRI of heart without contrast
• 75559 – MRI of heart with contrast
• 75561 – MRI of heart with and without contrast
• 75563 – MRI of heart with stress imaging
• 75565 – Cardiac MRI with flow mapping

ICD-10-PCS:

• B030ZZZ – MRI of heart

11). Myocardial Perfusion Imaging (Nuclear Stress Test)

What it is: A nuclear medicine scan that shows how well blood flows to the heart muscle during rest and stress.

Why doctors order it: To diagnose coronary artery disease, especially in patients with chest pain or reduced exercise tolerance.

CPT Codes: 

• 78451 – Single study at rest or stress
• 78452 – Multiple studies (rest and stress)
• 78453 – Planar imaging, single study
• 78454 – Planar imaging, multiple studies

ICD-10-PCS: 

• C220ZZZ – Planar nuclear medicine imaging of heart

Common Mistakes in Cardiography Coding and How to Avoid Them

Let’s have a look at the top mistakes made when coding non-invasive cardiology procedures, along with the tips to avoid them:

Using the Wrong or Old CPT Codes

Many coders accidentally use CPT codes that are out of date or don’t match the actual service performed. For example, using a full-service (global) code when only the interpretation was done.

How to avoid?

First, always check that you’re using the latest CPT codes. Secondly, be clear on what part of the service was provided either just the test or just the reading, maybe even both. Also, use modifiers like -26 for the doctor’s interpretation or -TC for the testing part only.

Example: Use 93000 if the ECG test and interpretation are both done. Use 93010 with modifier -26 if only the doctor’s reading is billed.

Not Matching the Right ICD-10 Diagnosis Code

Sometimes, the test is billed correctly, but it gets denied because the diagnosis code doesn’t explain why the test was needed. This often happens when coders use unclear or general diagnosis codes.

How to avoid?

Use specific ICD-10 codes that clearly show the test was medically necessary. Don’t just use general codes, check payer rules or tools like Medicare’s LCD/NCD lists to see which diagnoses are allowed for each test.

Tip: Create a quick-reference list of the most common ICD-10 codes used with each cardiology test.

Billing for Procedures That Are Already Bundled

Some non-invasive tests are bundled together by insurance, meaning they are paid as one service. But, coders may bill them separately by mistake, which can lead to denials or audits.

How to avoid?

First of all, check the NCCI edits to see if two procedures are bundled. If they’re normally billed together, but in your case they were truly separate, you may need to use a modifier like -59. Also, make sure your documentation clearly supports this.

Example: If you bill an Echocardiogram and a Doppler together, you must show they were both needed and done for different reasons, not just part of a routine test.

Misusing or Forgetting Modifiers

Modifiers help tell the full story of a service. For example, they explain whether only a part of it was done, or if it was separate from another procedure. Usually, many coders either forget to add the necessary modifiers or use the wrong ones. This can lead to underpayment, denials, or incorrect claims.

How to avoid?

Understand when and how to use common cardiology modifiers like:

Always make sure the documentation supports the modifier. Don’t just use them just to bypass edits, use them only when truly needed.

Example: If a Holter monitor is provided by an outside facility but interpreted in your office, use modifier -26 with the CPT code to bill only for the interpretation.

Quick Checklist for Easy and Accurate Cardiography Coding

Here is a quick checklist for you to follow. You’ll reduce billing mistakes, get paid faster, and make life easier for everyone in your cardiology practice.

Know What Test Was Done

First, understand if it’s a diagnostic, monitoring, or imaging test. Each one comes with different CPT/ICD codes.

Use the Right CPT Code

Double-check that you’re not using outdated codes. Refer to the AMA or coding software for updates.

Always Match CPT with the Right Diagnosis (ICD-10)

Avoid non-specific diagnosis codes. Use a diagnosis code (ICD-10) that clearly shows why the test was needed.

Don’t Forget Modifiers

Use modifiers like -26 (doctor’s part), -TC (test only), or -59 (separate service) when needed.

Watch for Bundled Services

Some tests are combined into one code. Use NCCI edits to prevent unintentional unbundling. Use modifier -59 only when services are truly distinct.

Check Insurance Rules

Every insurance plan is different, look up coverage rules before billing.

Document Everything Clearly

Ensure provider notes clearly explain what was done, why it was necessary, and who performed which part of the test.

Conclusion

Non-surgical heart tests may be simpler than surgical cardiography procedures, but coding them correctly requires the same focus. Also, knowing which non-surgical cardiography procedures are included in cardiology system coding is super important. Furthermore, these tests like ECGs, Echocardiograms, Stress tests, and Heart scans help doctors check heart health without any surgery.

Moreover, using the right CPT and ICD-10-PCS codes, checking the diagnosis, and adding the right modifiers can make a big difference in getting paid on time and avoiding rejections. Good coding helps patients, doctors, and cardiology billing teams all stay on track.

To sum up, when you know the right non-surgical heart tests and how to code them properly, you’ll avoid billing errors, reduce claim rejections, and make the whole process smoother for everyone.

That is why it’s important for individual providers and clinic owners to fully understand MIPS penalties and how to avoid them. Read on to dive deeper and contact us if you need help staying proactive and avoiding these penalties.

What are MIPS Penalties?

MIPS penalties are payment reductions given by the Centers for Medicare & Medicaid Services (CMS) to eligible clinicians who don’t meet the MIPS program’s performance standards.

MIPS, short for the Merit-Based Incentive Payment System, is CMS’s method for tying Part B Medicare payment to performance. While top performers can earn financial bonuses, those who don’t meet CMS’s annual performance threshold face penalties. These are reductions to future Medicare reimbursements.

MIPS penalties are calculated as a negative percentage adjustment, ranging up to -9%, based on a provider’s Composite Performance Score (CPS). Scores below the national threshold trigger penalties, applied two years after the performance year. For example, 2023 MIPS scores affect 2025 payments.

As CMS continues to raise standards, more clinicians, including physicians, nurse practitioners (NPs), and Physician Assistant (PAs), are being penalized. Unless exempt, any MIPS-eligible provider who fails to meet the required benchmarks is at risk.

Why Are MIPS Penalties Applied?

CMS uses MIPS penalties as a way to push providers toward better performance. The goal is simple: move the US healthcare system from volume-based to value-based care. This way, CMS encourages clinicians to improve outcomes, reduce costs, and report their data accurately.

These penalties are part of a budget-neutral system. That means money taken from low-performing clinicians is used to reward high performers. The structure helps promote fairness and continuous improvement, but it also creates pressure. Even small mistakes or missed submissions can lead to a loss in revenue.

CMS enforces MIPS penalties through the Quality Payment Program (QPP). Each year, it reviews submitted data, sets a performance threshold based on national averages, and determines payment adjustments. As participation grows and thresholds rise, more providers risk falling below the cut-off. The system is built to reward effort, but it also punishes gaps.

How Do MIPS Penalties Work?

MIPS penalties work by cutting into a provider’s Medicare Part B payments. If you don’t meet the minimum score set by CMS for a given year, you get paid less, up to 9% less, depending on how far below the cutoff your score falls.

Here’s how the process works:

First, CMS evaluates each provider’s performance across four categories:

• Quality (30%)
• Promoting Interoperability (25%)
• Improvement Activities (15%)
• Cost (30%)

Your performance in each category is scored and combined into one number: your Composite Performance Score (CPS). Each year, CMS sets a performance threshold, a minimum CPS you must reach to avoid penalties.

For example, the threshold for the 2023 performance year (which affects 2025 payments) is 75 points out of 100.

If your CPS is below that threshold, CMS applies a negative payment adjustment to your Medicare claims. The size of the penalty depends on how far below the cutoff your score is. Clinicians who score 0 to 18.75 points receive the maximum penalty: -9%. Those closer to the threshold receive smaller cuts on a sliding scale.

The penalty doesn’t come all at once. It’s applied throughout the year to every Medicare Part B payment you receive, starting two years after the performance year.

Penalties are calculated at the TIN/NPI level, which means CMS can apply them to an individual clinician or to everyone in a group.

What Triggers a MIPS Penalty?

MIPS penalties are triggered when your Composite Performance Score (CPS) falls below the annual performance threshold set by CMS. For the 2025 payment year, that threshold is 75 points.

The most common triggers include:

Not Reporting Data

If you skip MIPS reporting entirely, CMS assigns you a score of zero. That means the maximum penalty of -9% is automatically applied.

Reporting Incomplete Data

Submitting data for only some categories or leaving out required fields lowers your score. Partial reporting can easily push your CPS below the threshold, even if your performance is decent.

Poor Scores Across Categories

You might submit everything, but low scores in one or more categories (like Quality or Cost) can drag down your overall CPS.

Falling Just Short of the Threshold

Even if you score 74.99 points, you still get penalized. That’s because CMS enforces the threshold strictly. There’s no rounding up.

Tech or Submission Errors

Using outdated software, submitting incorrect files, or missing deadlines can all impact your score, or cause your data to be rejected entirely.

Misunderstanding the Rules

MIPS rules change each year. Many providers get penalized not for poor care, but for not keeping up with the latest requirements.

In short, MIPS penalties aren’t just for those who do nothing. They can hit providers who try to comply but fall short on score, submission quality, or simply due to an oversight. And once triggered, those penalties affect every dollar billed to Medicare Part B for the entire adjustment year.

What Is the Penalty for Not Reporting MIPS?

If you don’t report MIPS data at all, and you’re not exempt, you’ll get hit with the maximum penalty. That means a 9% cut on all your Medicare Part B payments for the corresponding payment year. No data? Full penalty.

Here’s what that looks like in practice:

If a clinician bills $250,000 to Medicare Part B in a year, a 9% penalty means losing $22,500 in revenue. That’s a serious drop, especially for small or solo practices where margins are tight. This penalty doesn’t come in one lump sum. Instead, CMS reduces every Medicare payment by 9% throughout the year.

Does Practice Size Matter for MIPS Penalties?

Yes. The impact of MIPS penalties can be especially hard on small practices.

➜ Small practices: In 2022, about 27% of small practices and nearly 30% of solo clinicians received MIPS penalties (Source).

➜ Larger organizations: Bigger practices are more likely to have teams and tech to handle MIPS reporting, so they tend to avoid penalties more easily.

Even if you’re part of a group, failing to report individually (or not participating as a group) can still lead to individual-level penalties.

And it’s not just financial.

Not reporting MIPS also means you lose:

• A chance to earn positive payment adjustments.
• Visibility on CMS’s Care Compare site (which can affect patient trust).
• Access to performance feedback reports that help you improve care quality.

Some clinicians are exempt from MIPS automatically. These include:

• Providers new to Medicare in their first year.
• Those below the low-volume threshold (Under $90,000 in Part B charges or fewer than 200 Medicare patients).
• Participants in Advanced Alternative Payment Models (APMs).

If you’re not sure whether you qualify for an exemption, check directly with CMS or use their QPP participation status here.

MIPS Penalties by Year (Historical Trends)

Since MIPS began, CMS has steadily increased both the penalty amounts and the difficulty to avoid them. The performance threshold has gone from just 3 points in 2017 to a demanding 75 points by 2022, and it’s stayed there.

Here’s a clear breakdown:

MIPS Penalties: Impact, Criticism, and What Lies Ahead

For providers, the effects of MIPS penalties are wide-reaching. Financial losses from a full -9% cut can total tens of thousands of dollars, hitting small and solo practices the hardest.

Beyond lost revenue, compliance itself is resource-heavy. Accurate reporting across MIPS’s four categories; quality, cost, improvement activities, and interoperability, requires time, technology, and staff many practices lack. This burden often forces operational changes, from hiring consultants to investing in new EHRs or reorganizing workflows.

But the toll is more than operational.

Clinicians report burnout and frustration, especially when penalties stem from reporting technicalities rather than actual care quality. The pressure to meet metrics can pull focus from patient care, reducing both outcomes and satisfaction.

Also, MIPS scores are public, and a low rating can hurt a provider’s reputation, regardless of clinical performance. Appeals are allowed, but limited and often ineffective.

Criticism of the system is mounting. MIPS disproportionately penalizes small, rural, and independent practices that lack the resources for full compliance.

In 2024 alone, 27% of small practices and 18% of rural ones were penalized. Specialty providers, such as anesthesiologists and orthopedic surgeons, have also faced outsized challenges.

MIPS requires physicians to track and report across multiple categories, quality, cost, improvement activities, and interoperability. A JAMA study found that MIPS compliance costs about $12,811 per physician each year and eats up over 200 hours, time that could be spent on patient care.

Calls to cut MIPS burden are gaining traction. Physician groups like the American Medical Association (AMA) support replacing MIPS with the Data-Driven Performance Payment System. The new proposed program is reported to reduce penalties, simplify reporting, and better align metrics with care quality.

How to Avoid MIPS Penalties

Avoiding MIPS penalties takes more than last-minute reporting. It requires proactive steps throughout the year. Here are proven ways to stay penalty-free:

• Check your MIPS eligibility with CMS at the start of the year
• Know the annual performance threshold (75 points for 2024)
• Start early with your data collection and tracking
• Submit complete and accurate data in all four MIPS categories
• Choose quality measures that match your specialty and practice
• Use certified EHR systems effectively to boost your Promoting Interoperability score
• Engage in high-impact Improvement Activities like care coordination and telehealth
• Track your MIPS performance monthly to catch issues early
• Involve your entire care team in documentation and workflow alignment
• Standardize checklists for visits to capture key MIPS data points
• Use dashboards or tools that show your real-time performance
• Conduct internal audits before submitting your final data
• Report bonus-eligible activities to gain extra points
• Document everything, CMS may request proof of activities
• Partner with MIPS consulting services if unsure how to improve your score

This guide helps therapy and mental health providers understand BCBS reimbursement for therapy services across different states. This will help optimize payments, avoid medical billing errors, and manage insurance complexities. Let’s dive in!

Understanding the Ins and Out of Therapy Reimbursement

Reimbursement means getting paid by insurance after providing therapy. As a provider, you send a claim to Blue Cross Blue Shield for each session. They then pay you based on your contract or the patient’s plan. If you’re in-network, BCBS usually pays more and faster. If you’re out-of-network, payments are lower, and the process is slower.

Common Challenges Mental Health Therapists Face

• BCBS reimbursement isn’t always smooth.
• Providers often deal with delayed payments, claim denials, or partial reimbursements.
• Each state’s BCBS company may follow different rules.
• Keeping up with their requirements takes time.
• Missed coding or documentation issues can also delay or reduce payment.
• To stay on top, know your local BCBS policies and track each claim carefully.

How Much Does Blue Cross Blue Shield Reimburse for Therapy (Mental Health)?

Blue Cross Blue Shield reimburses therapy costs based on the patient’s coverage details like deductibles, copays, or coinsurance. In-network therapists generally have lower copays, ranging from $15 to $80 per session. Some plans allow coverage before the deductible is met, while others require patients to pay the full session fee until the deductible is reached.

Remember, these are just the estimates!

Reimbursement rates for therapy vary widely depending on where you practice. Since BCBS is made up of 33+ independent companies across the US, each with its own fee schedules and policies, rates can shift from one state to another, even for the same CPT code.

If you’re a therapy provider, knowing these state-specific benchmarks can help you:

• Set realistic rates.
• Negotiate better contracts with BCBS.
• Decide whether going in-network is financially worthwhile.
• Understand potential revenue when expanding to new states or offering telehealth.

BCBS Therapy Reimbursement Rates (State-wise)

The below-given table provides real-world estimates for 60-minute psychotherapy sessions (CPT Code 90837) across all 50 states, based on provider reports, claims data, and BCBS regional trends. These figures are approximate and can vary based on specific BCBS affiliates, provider contracts, and geographic regions within each state.

Factors Influencing BCBS Therapy Reimbursement Rates for Providers

In-network rates are based on negotiated contracts with local BCBS affiliates. Out-of-network payouts are often a percentage of the plan’s “allowed amount” (typically 60–80%) and subject to balance billing. Urban providers generally receive slightly better reimbursements due to market demand and parity compliance. Let us quickly discuss the many factors that affect how much BCBS reimburses for therapy services.

1. Geographic Location and Cost of Living

Reimbursement rates often reflect the local cost of living and provider density. Urban areas with higher living costs and more providers may offer higher rates to attract professionals. And rural areas might offer increased rates to incentivize providers to serve underserved populations.

2. Type of BCBS Plan

The specific BCBS plan type, such as PPO, HMO, or HDHP, can influence reimbursement rates. PPO plans often provide higher reimbursement rates due to their broader network flexibility, whereas HMO plans may offer lower rates but with more controlled access to services.

3. Provider’s Contract Status with BCBS

Providers contracted with BCBS typically receive higher reimbursement rates compared to out-of-network providers. In-network status ensures adherence to negotiated rates and reduces administrative burdens, leading to more predictable payments.

4. Session Length and Complexity

The duration and complexity of therapy sessions directly impact reimbursement rates. Longer sessions or those involving complex therapeutic techniques may warrant higher reimbursement due to the increased time and expertise required.

5. Legislative and Policy Factors

Legislative actions, such as changes in Medicare payment policies, can significantly affect reimbursement rates. For example, the Centers for Medicare & Medicaid Services (CMS) has implemented reductions in the Medicare conversion factor, leading to decreased payments for services unless offset by legislative intervention.

6. Economic and Cost Factors

Economic indices, like the Medicare Economic Index (MEI), reflect the rising costs of providing services. However, reimbursement rates may not always align with these increases due to budget constraints, potentially leading to financial strain for providers.

7. Therapy-Related Clinical Factors

The type of therapy provided influences reimbursement rates. Specialized services, such as psychiatric evaluations or neuropsychological testing, often command higher reimbursement due to their complexity and resource requirements.

8. Provider Credentials and Network Status

Providers with advanced qualifications such as, LCSW, PsyD, or MD may receive higher reimbursement rates due to their expertise. Additionally, being in-network with BCBS can lead to better reimbursement rates compared to out-of-network providers.

9. Insurance Plan and Payer Differences

Reimbursement rates vary among different insurance panels and plans. For instance, Medicare Advantage plans have seen reimbursement increases, while traditional Medicare rates have declined, highlighting the differences in payer policies.

10. Practice Expense and Procedure Mix

The reimbursement impact of changes in practice expenses depends on the share of Relative Value Units (RVUs) attributed to practice expenses for a given service. Services with a higher practice expense share may experience more significant reimbursement changes when adjustments are made.

How Telehealth Affects How Much Does Blue Cross Blue Shield Reimburse for Therapy?

Telehealth has become a key component of therapy services, especially post-COVID-19. BCBS now reimburses telehealth sessions, typically at rates similar to in-person therapy. However, reimbursement can vary based on location, therapy type, and the specific BCBS plan. Some regions may offer lower rates for telehealth, so providers must be aware of these differences.

BCBS Telehealth Reimbursement Policies

State-specific telehealth parity laws impact BCBS reimbursement policies. These laws require BCBS to reimburse telehealth sessions at the same rate as in-person visits, but the rules differ by state. Mental health and therapy providers should check local telehealth regulations and ensure they follow BCBS’s policies when submitting claims.

How to Ensure Telehealth Claims Are Paid Correctly

To ensure correct reimbursement for telehealth, therapists must use the correct billing codes, such as the “GT” modifier for telehealth services. It’s crucial to verify patient eligibility, document sessions thoroughly, and apply the right modifiers and CPT codes. Following these practices helps avoid claim denials and delays, ensuring timely reimbursement for virtual therapy sessions.

How BCBS Plans and Their Therapy Coverage Compare

Blue Cross Blue Shield offers a variety of health insurance plans, each with unique structures and therapy coverage options. Understanding how these plans compare is essential for providers seeking to navigate reimbursement processes.

1. HMO (Health Maintenance Organization) Plans

HMO plans require members to use in-network providers and often need a referral from a primary care physician (PCP) for therapy. Therapy coverage is generally limited to in-network services, except for emergencies. These plans tend to have lower premiums and out-of-pocket costs, but the flexibility is restricted.

2. PPO (Preferred Provider Organization) Plans

PPO plans offer more flexibility, allowing members to see out-of-network providers, though at a higher cost. Therapy services are typically covered, with better rates for in-network visits. Members can still access therapy outside the network, but at higher out-of-pocket costs and lower reimbursement rates for providers.

3. EPO (Exclusive Provider Organization) Plans

EPO plans are similar to PPOs but only cover in-network therapy services. They do not require a referral from a PCP to see a therapist, which offers more convenience for patients. However, out-of-network therapy is not covered under EPO plans, making it important for providers to ensure they are in-network to receive reimbursement.

4. POS (Point of Service) Plans

POS plans require a PCP referral for therapy services but offer some flexibility to access out-of-network care. Therapy is covered, but costs are lower when providers are in-network. Out-of-network services may be reimbursed, but at a higher cost to the patient and potentially lower reimbursement to the provider.

5. Consumer Directed Health Plans (CDHP) and High Deductible Health Plans (HDHP)

These plans feature high deductibles but allow members to use Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs) to cover therapy costs. Therapy services are covered but require the deductible to be met first. CDHP and HDHP plans are suitable for providers seeking patients who prefer a lower monthly premium, but reimbursement rates may be delayed until deductibles are satisfied.

6. Catastrophic Plans

Catastrophic plans offer low premiums but high deductibles. They are designed for young adults or those facing financial hardship. Therapy coverage is minimal until the deductible is met, meaning therapy services are generally not reimbursed unless the patient has high healthcare needs.

7. Medicare and Medicaid Plans

BCBS offers Medicare Advantage and Medicaid plans, both of which provide comprehensive therapy coverage. Medicare Advantage plans typically cover outpatient therapy and psychiatric services, with cost-sharing based on Medicare rules.

Medicaid plans provide extensive behavioral health coverage, including therapy services, usually with low or no out-of-pocket costs for those who qualify.

Benefits of Using BCBS Insurance for Mental Health Conditions

Blue Cross Blue Shield insurance offers these valuable advantages for therapy providers.

• Reduces out-of-pocket costs for clients, increasing access to your services
• Expands your client base through BCBS’s extensive network
• Provides reimbursement for various treatment types, including specialized therapies
• Offers flexibility with telehealth and in-person service coverage
• Ensures privacy and compliance, protecting both your practice and client data

FAQs on BCBS Therapy Coverage and Reimbursements

Let us answer a few questions about BCBS therapy reimbursements now.

Do I need to verify patient eligibility for therapy services?

Yes, providers must verify patient eligibility before delivering therapy services. This ensures that the patient’s insurance plan covers the required therapy and that there are no issues with eligibility. To verify, you can use the BCBS provider portal, contact BCBS customer service, or use an eligibility verification system if your practice has one. Always confirm the patient’s benefits to avoid claim rejections.

How do I file a claim for therapy services under BCBS?

To file a claim for therapy services under BCBS, follow these steps:

1. Ensure you have the correct CPT codes, dates of service, and diagnosis codes.
2. Use the BCBS provider portal for electronic submission or mail the claim to BCBS using the address specified on the provider’s website.
3. Track the claim status through the portal or by calling BCBS if needed. Comply with any specific instructions provided by BCBS to avoid delays.

How long does BCBS take to process therapy claims?

On average, BCBS processes therapy claims within 30 to 45 days. However, this time frame can vary depending on several factors, such as claim complexity, network status (in-network or out-of-network), and plan type. You can track the status of claims through the BCBS provider portal for updates.

What should I do if BCBS refuses to pay for therapy services?

If BCBS denies a therapy claim:

1. Check the reason provided in the denial notice.
2. Call the BCBS provider support line for clarification on the denial and gather more information.
3. If you believe the denial was made in error, follow the appeal instructions. This may involve submitting additional documentation to support the claim. Use the correct appeals forms and ensure all required information is provided to avoid further delays.

Does Blue Cross Blue Shield cover therapy services?

Yes, BCBS generally covers therapy services, including individual and group psychotherapy, psychiatric evaluations, and other mental health services. However, coverage can vary based on the patient’s specific plan type, network status, and location. Ensure to check the patient’s plan benefits for details on coverage, limitations, and reimbursement rates.

How do I verify if therapy is covered by a patient’s BCBS plan?

To verify coverage for therapy, check the patient’s Summary of Benefits for the “Outpatient Mental Health” section. You can also use the BCBS provider portal or call BCBS member services to confirm the patient’s therapy benefits, network requirements, and any prior authorization needs.

Can I submit claims for telehealth therapy sessions?

Yes, BCBS covers telehealth therapy, but reimbursement rates may differ from in-person therapy. Providers should use the appropriate telehealth CPT codes (such as 90834 for psychotherapy, 30 minutes) and include the GT modifier to indicate telehealth. Ensure you follow BCBS’s telehealth guidelines and claim submission procedures to ensure timely and accurate reimbursement.

What if the patient chooses an out-of-network therapist with BCBS?

If the patient is seeing an out-of-network therapist, reimbursement will likely be at a lower rate. The patient may be responsible for higher out-of-pocket costs, and you may need to submit a claim for reimbursement if you’re an out-of-network provider. PPO plans typically reimburse some portion of the out-of-network therapy fees, while HMO or EPO plans usually do not reimburse for out-of-network services.

How can I avoid claim denials and ensure correct payment?

To reduce the likelihood of claim denials, follow these best practices:

1. Always verify patient eligibility and coverage before delivering services.
2. Use accurate CPT, ICD-10, and modifier codes.
3. Ensure thorough and complete documentation of each session, including the treatment provided and progress made.
4. Submit claims within the required timeframe and use electronic medical billing service whenever possible to speed up processing.
5. Regularly track claims status and follow up with BCBS if necessary.

If you have ever wondered “in what format are healthcare claims sent?” this guide answers that question and shows how the right claim submission format keeps healthcare reimbursements moving.

A clean claim starts the payment clock. Use the wrong healthcare claims format or leave out key data, and the clock stops. Insurers then delay, reduce, or even refuse payment. Knowing what format healthcare claims are submitted in—and using it every time—guards your cash flow.

You will hear two close‑sounding terms: ‘form’ and ‘format’. They sound alike, but here’s an easy way to keep them straight:

• Form = paper. Think CMS‑1500 or UB‑04.
• Format = electronic. Think files that zip through secure networks.

That shift from form to format changes the game. Paper forms still work for a few small offices, yet they move at postal speed and add data‑entry risk. In contrast, an electronic medical claim form format reaches the payer in minutes and meets every HIPAA‑compliant medical claim format rule.

Most healthcare providers now rely on the HIPAA‑compliant 837 electronic insurance claim format because it moves fast and cuts errors. The 837 family has three files:

• 837P (Professional): office visits, lab work, therapy, and other outpatient care
• 837I (Institutional): hospital stays, skilled‑nursing days, and other facility fees
• 837D (Dental): cleanings, fillings, crowns, and all oral services

Additionally, pharmacies follow a different (but equally strict) insurance claim format called NCPDP for every prescription they fill.

⫘⫘⫘⫘⫘⫘

In the United States, healthcare claims move in matched pairs of paper and electronic files. When paper is still required, providers mail the CMS-1500 for office services, the UB-04 (CMS-1450) for hospital or facility charges, and the ADA Dental Claim for tooth work.

Day-to-day, those same claims travel faster as their electronic twins—the CMS-1500 turns into the 837P, the UB-04 turns into the 837I, the ADA form turns into the 837D, and every paper pharmacy slip converts to the NCPDP telecom file. All four digital files ride on secure EDI, making them the standard format for submitting medical claims today.

⫘⫘⫘⫘⫘⫘

What is meant by the ‘format’ of a Healthcare Claim?

When people ask “in what format are healthcare claims sent?” they are talking about the exact layout—paper or electronic—that tells an insurer who was treated, what was done, when it happened, and how much it cost. In the United States, providers must send this information in a HIPAA‑compliant medical claim format so the payer can read it, check it, and pay it without delay.

Every claim line follows a standard format for submitting medical claims and carries well‑known code sets:

• ICD‑10‑CM — pinpoints the diagnosis
• CPT® or HCPCS — shows the procedure or service
• NDC, HCPCS Level II, or revenue codes — identify supplies, drugs, devices, or medical transport

Using the right healthcare claims format reduces back‑and‑forth, slashes errors, and speeds up cash flow. Put simply, the format is the blueprint that turns clinical work into dollars received.

Who decides the healthcare claim submission format?

Before you hit “send,” you need to know who writes the rules. In U.S. healthcare, four main bodies define what format healthcare claims are sent in and how those files must look. Master their playbook, embed them in your practice management software, and your claims move from “pending” to “paid” much faster.

1). Centers for Medicare & Medicaid Services (CMS)

CMS issues the familiar paper layouts, called the CMS‑1500 for professional services and the UB‑04 for hospital billing and facilities. Even in an e‑first world, many healthcare payers still scan these forms, so clean, crisp fields matter. As a healthcare provider, you need to follow every box, line, and font cue so that your paper claim sails through optical‑character recognition with fewer manual touch‑ups.

2). Accredited Standards Committee X12 (often called ANSI X12)

When you switch to electronic, X12 owns the road. Its 837P, 837I, and 837D EDI loops translate your service lines into machine‑readable data. The latest release—HIPAA version 5010—locks down field length, segment order, and code sets. Submit an 837 file that matches X12 specs and most clearinghouses will approve it in minutes.

3). National Council for Prescription Drug Programs (NCPDP)

Need to bill a pharmacy claim? NCPDP frames the real‑time electronic medical claim format for retail, mail‑order, and specialty drugs. It syncs each NDC code, quantity, and day‑supply field so the payer’s drug‑utilization engine can check safety and price in a single ping.

4). Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is the federal backbone. It mandates that every covered entity—clinic, dentist, hospital, or health plan—uses a HIPAA‑compliant medical claim format and safeguards patient data at rest and in flight. Fail to follow these guardrails and you risk fines, data breaches, and slow payment.

Types of Healthcare Claim Form formats

1). the CMS‑1500 Paper Claim Format

Even in the EDI era, some payers still need a paper file. That file is the CMS‑1500 form. It is the standard insurance claim format for solo doctors, therapists, labs, and other non‑facility providers. Think of it as the paper twin of an 837P file. If you mail or fax a claim, this is the one that lands on the payer’s scanner.

Why CMS‑1500 is a standard claim format?

The CMS‑1500 is more than a sheet of paper. It follows firm layout rules that turn your data into a machine‑ready healthcare claims format:

• Fixed field map. Each red box lines up with a matching data field in HIPAA’s 837P file. That one‑to‑one link keeps your claim submission format in sync whether you print or send EDI.
• Code sets locked in. The form forces you to use ICD‑10‑CM for diagnoses, CPT®/HCPCS for services, and your ten‑digit NPI for provider ID. Those sets make the file a HIPAA‑compliant medical claim format by design.
• Scanner‑friendly ink. The “drop‑out” red ink lets optical readers lift each character cleanly. A clear scan speeds the payer’s first‑pass edit and cuts denials.

Because its layout never changes, the CMS‑1500 acts as a standard format for submitting medical claims (even when you submit on paper).

Why polish your CMS‑1500 workflow?

• Fewer re‑works. A tight, HIPAA‑compliant medical claim format gets past OCR edits on the first scan.
• Quicker cash flow. Clean paper claims can still clear in ten business days. This is vital when clearinghouses are down.
• Easy pivot to EDI. Every well‑filled CMS‑1500 mirrors the field order of an 837P. When you upgrade, the map is ready.

2). the UB‑04 (CMS‑1450) Facility Claim Format

Hospitals, rehab centers, and skilled-nursing homes do not bill on the CMS‑1500 claim format. Instead, they use the UB‑04 form, also called CMS‑1450. This single page carries every charge for a full stay—room, board, drugs, supplies, lab work, even the swing‑bed fee. So if you ask in what format are healthcare claims sent for facilities?, the answer is almost always UB‑04 in paper or 837I in EDI.

What makes the UB‑04 a standard format?

• Fixed line map. Every line has a locator number (FL 01–81). That grid links one‑for‑one with the 837I segments in a HIPAA 5010 file, keeping your healthcare claims format consistent across paper and electronic routes.
• Revenue codes first. Each charge line starts with a three‑digit revenue code, then the CPT®/HCPCS code when needed. This layout meets the healthcare claim submission format requirements that drive auto‑adjudication.
• Header holds payer data. The top blocks lock in Medicare, Medicaid, or private plan IDs. Drop the wrong payer code and the claim bounces before anyone checks medical need.

Sections you must get right:

• Patient and subscriber data (FL 12–17). Copy the name, date of birth, and member ID exactly from the card.
• Occurrence and value codes (FL 31–41). These tiny two‑digit flags mark why the stay started, when benefits kicked in, and how much the patient paid.
• Service lines (FL 42–47). List each daily room rate, therapy charge, or drug cost on its own line so the payer’s system can total them.

3). the ADA Dental Claim Format

Dentists do not bill on a CMS form. They use the ADA Dental Claim Form, built by the American Dental Association for easy review by dental payers. It runs on paper or as an electronic flat file that mirrors its boxes.

Key details the form captures:

• Patient facts. Full name, birth date, address, policy or group number.
• Provider identity. Dentist’s name, NPI, practice address, phone, and pay‑to number.
• Service codes. Each procedure uses a CDT code (e.g., D1110 for adult cleanings).
• Tooth data. The form shows tooth numbers, surfaces, and quadrants to prove need.
• Clinical notes. A short box lets you add a narrative. This is beneficial for crowns, implants, or ortho claims because payers need clear proof of medical need (cracks, bone loss, malocclusion) before they sign off on these higher‑cost services.

Why this dental format matters?

• Uniform language. CDT codes and tooth charts let payers price claims fast.
• HIPAA alignment. The form meets HIPAA‑compliant medical claim format rules and maps straight to the 837D EDI file.
• Low denial risk. *Clear tooth surfaces and dates stop “lack of info” rejections that delay checks.

4). the Workers’ Compensation Claims Format

When an injury happens on the job, the claim does not go through a regular health plan. Instead, you bill the employer’s workers’ comp carrier in a special healthcare claims format that mixes state rules with HIPAA data sets.

What format are workers’ comp claims submitted in?

• Paper route. Many carriers still ask for a CMS‑1500 marked “Workers’ Compensation” in Box 10 d. Attach state‑required injury reports and mail the bundle to the adjuster.
• Electronic route. Larger payers accept an ANSI X12 837P or 837I file plus the state’s claim number in Loop 2300. This meets HIPAA‑compliant medical claim format rules while flagging the file as work‑related.

Either way, use the standard format for submitting medical claims. But add the extra comp fields listed below so the adjuster can link services to the injury event.

Must‑have fields that keep the claim moving:

• Employer data. Full company name, address, and the workers’ comp policy number prove coverage.
• Employee facts. Name, home address, birth date, and Social Security number pin the claim to one worker.
• Injury snapshot. Date, time, and place of the accident, plus a short injury story (e.g., “strained lower back lifting boxes”).
• Service lines. List each CPT® or HCPCS code, tied to ICD‑10‑CM trauma codes (S‑ and T‑series) that match the injury note.
• Claim number. The state or carrier issues this after the first report of injury. Put it on every claim so payment flows to the right file.

5). the Coordination of Benefits Claim Format

Patients who have two or more health plans need a clear hand‑off. That hand‑off happens in the Coordination of Benefits (COB) claim format—the fields inside every paper and electronic claim that tell payers who pays first and who pays next.

“Who pays first” means the primary plan—the policy that has the legal duty to process the bill before any other insurer. It allows or denies each charge, applies its own deductible or copay rules, and sends an Explanation of Benefits (EOB) that shows what it paid and what is still owed.

“Who pays next” refers to the secondary (or tertiary) plan. This plan cannot act until it sees the primary EOB. Once it has that record, it:

• checks the remaining balance,
• pays up to its own benefit limits, and
• may wipe out the left‑over patient share.

Example: A patient has an employer health plan and is also covered under a spouse’s plan. The employer plan is primary, so it handles the claim first. After it posts payment, you transmit the same claim—with the primary paid amount filled in—to the spouse’s plan. That plan is secondary and can now cover some or all of the leftover cost.

Stating this order in the COB claim format keeps every payer in line with federal Coordination‑of‑Benefits rules, stops over‑payment, and ensures the patient never gets billed twice for the same care.

When someone asks “in what format are healthcare claims sent when the patient has double coverage?” the answer is: CMS‑1500 or UB‑04 on paper, and ANSI X12 837 with COB loops on EDI.

What the COB data must show?

➜ Each policy in plain view

• Insurance name, plan type, and policy number
• Start and end dates so the payer sees the coverage line‑up

➜ Benefit check

• Does the plan pay primary or secondary on this visit?
• Any carve‑outs or limits that change how much it will cover

➜ Payment order

• You mark the primary carrier first, the secondary carrier second, and so on
• In an 837 file, this sits in Loop 2320—HIPAA’s built‑in spot for COB rules

Why the COB format cuts claim ping‑pong?

• Stops over‑payment. Clear policy data keeps payers from paying more than the charge.
• Speeds split‑payment. When the primary plan’s paid amount drops into the secondary plan’s field, the second payer can finish the bill without calling you.
• Meets every rule. COB elements sit inside the same HIPAA‑compliant medical claim format you already use, so you stay within federal privacy guardrails.

6). the Medicare and Medicaid Claim Form Formats

Federal payers follow strict layout rules. When you bill Medicare or Medicaid, you choose the claim format first, then you fit every field to the CMS guide.

Pick the right form or its EDI twin:

• CMS‑1500 / 837P – Use this medical claim format for professional work: office visits, lab draws, therapy, ambulance runs.
• UB‑04 / 837I – Use this format for facility fees: hospital stays, rehab days, dialysis, outpatient surgery.

Think of the paper form as a picture of the electronic file. The boxes on the page map line-for-line to the segments in the ANSI X12 file. That link keeps each claim HIPAA-compliant and easy to read by Medicare’s edits.

Key Medicare-Medicaid format rules:

• Use the right code sets. Stick to ICD‑10‑CM for the “why,” CPT®/HCPCS for the “what,” and revenue codes for room and board.
• Show the NPI every time. Place your ten-digit NPI in the provider ID box and in Loop 2010AA of the 837 file.
• Add the payer ID. Medicare uses payer ID “CMS.” State Medicaid plans list their own four- or five-character IDs—check your remittance advice if you forget.
• Lock the date style. Medicare denies claims with slashes. Enter dates as MMDDYYYY on paper and as CCYYMMDD in EDI.
• Include signature on file. On the CMS‑1500, mark “Signature on File” in Box 12 and Box 13. In the 837P use the HI segment flag. This shows you hold the patient’s consent.

Electronic Claim Formats

Manual Claim Formats

FAQs

What is primary and secondary insurance?

Primary insurance is the first plan that reviews your claim and pays up to its own benefit limits. Secondary insurance steps in after the primary issues an Explanation of Benefits (EOB) and covers some or all of the leftover bill. Clear COB data on your claim tells payers in what order to pay.

What is the difference between a claim form and a claim format?

Form = a paper document (CMS-1500, UB-04, ADA) you print, sign, and mail or fax.
Format = an electronic data file (837P, 837I, 837D, NCPDP) you send through EDI. Each format mirrors its paper twin and meets all HIPAA-compliant medical claim format rules.

What is the CMS-1500 form used for?

Providers submit professional services—office visits, therapy, lab draws—on the CMS-1500 paper claim form when electronic filing is not an option.

What is the UB-04 form used for?

Hospitals, rehab centers, and skilled-nursing homes bill inpatient stays and other facility fees on the UB-04 (also called CMS-1450) when a payer still requires paper.

What does the 837P format represent?

The 837P is the electronic medical claim form format that replaces the CMS-1500. It travels by HIPAA-secure EDI and speeds professional claim processing.

How does the 837P differ from the 837I?

The 837P carries professional claims (outpatient visits, ambulance runs). The 837I carries institutional claims (inpatient room charges, outpatient surgery). Both follow the ANSI X12 healthcare claims format.

Why do most payers prefer electronic submission?

Electronic claims reach payers in seconds, cut keystroke errors, and meet every healthcare claim submission format requirement under HIPAA. Faster in, faster paid.

What is EDI in healthcare billing?

Electronic Data Interchange (EDI) is the secure network that moves 837 claim files, 835 remittances, and 270/271 eligibility checks between providers and payers.

Can I still use paper claim forms under HIPAA?

Yes. Smaller clinics and some state programs may mail claims. Yet most carriers now ask, “in what format are healthcare claims sent?”—and expect the electronic answer. Submitting the correct electronic claim format (837P, 837I, 837D, or NCPDP) speeds payment and keeps you compliant.

How can a medical billing service help with claim submission and denial management?

A medical billing services company knows every healthcare claims format inside out. It scrubs your data before you send a CMS-1500, UB-04, 837P, or 837I, catching code or NPI errors that cause denials. The team transmits each claim through its own high-speed clearinghouse link, tracks the payer’s edits in real time, and fixes any rejections the same day. When a denial does occur, the service applies denial management best practices and pulls the EOB, adds the missing detail, files an appeal, and resubmits in the proper claim submission format (often within 24 hours).

It might seem like a small thing, but in medical billing, it’s a big deal. If you bill the wrong insurance first, the claim can get denied. Payments can be delayed. Worst of all, your patient might get charged for something that should have been covered.

This simple guide will help you figure out the correct billing order. You’ll learn how to spot the primary insurance and the secondary insurance. So that you can bill the right one at the right time. And get paid faster for your services provided to the patients.

What Does “Primary” vs. “Secondary” Mean in Insurance?

Knowing who pays first is key in healthcare billing. It helps you avoid surprise bills. It also ensures claims are handled the right way. And if a claim is denied, you’ll know which insurance to follow up with first.

If the primary insurance denies a claim—because of eligibility issues or wrong details—the secondary insurance usually won’t pay either. That’s because they wait for the primary to process everything first.

So, before billing, it’s important to understand what primary insurance means—and how it’s different from a secondary plan.

1⃣ Primary Insurance in Healthcare Billing

Primary insurance is the first plan that pays when a patient gets medical care and a bill is generated. Think of it like the first responder in the billing process.

If a patient has more than one health insurance plan—like one through their job and another through a spouse or parent—one plan must take the lead. That lead plan is called the primary insurance.

This plan processes the claim first. It reviews the bill, decides what’s covered, and then pays its part to the healthcare provider.

For example:

If the total bill is $1,000 and the primary plan covers $700, it pays that $700 directly to the provider. The remaining $300 may then be sent to the secondary insurance, if there is one.

Knowing which plan is primary helps healthcare providers bill correctly and helps patients avoid delays or unexpected charges.

In short:

• Primary insurance pays first
• It sends payment to the healthcare provider
• It guides the rest of the billing process
• It’s important for both patients and providers to get this right

2⃣ Secondary Insurance in Healthcare Billing

Secondary insurance is the plan that pays after the primary insurance has done its part. It works like a backup—a financial safety net for both the patient and the healthcare provider.

Why a safety net? ➜ Because it helps catch leftover costs that the primary plan doesn’t fully cover. This could include things like co-pays, deductibles, or any unpaid portion of a medical bill. For the patient, this means fewer out-of-pocket expenses. For the provider, it means a better chance of receiving full payment without chasing it later.

Once the primary plan processes the claim and pays its share, the secondary insurance takes a look at the rest. It may cover all or part of the remaining balance.

For example:

• A medical bill is $1,000
• Primary insurance pays $700
• $300 remains

That’s when the secondary insurance steps in. Depending on its rules, it might cover some or all of that leftover amount.

It may help pay for:

• Co-pays
• Co-insurance
• Deductibles
• Services not fully covered by the primary insurance

*Note: Secondary Insurance never pays first. It waits for the primary insurer to finish. And it will never pay more than the actual cost of the service.

Primary vs. Secondary Insurance Comparison Table

Step-by-step Process to determine Primary and Secondary Insurance Plans

You’re treating a patient who has more than one health insurance plan—now what? No need to stress.

As a healthcare provider, it’s important to know exactly which plan is primary and which is secondary. This way you can bill correctly and avoid insurance reimbursement delays or denials.

This section walks you through a simple, step-by-step process to help you identify the correct billing order for your patient’s insurance plans.

Step 1: Gather Complete Insurance Information

Before you can figure out which insurance is primary and which is secondary, you need accurate and latest details on the patient’s health insurance plans. This step should always happen during patient registration—whether it’s a new patient or someone you’ve seen before.

Start by asking the right questions:

• “Do you currently have more than one active insurance plan?”
• “Who is the policyholder for each plan—you, your spouse, or a parent?”
• “Is the coverage through an employer, government program, or private provider?”
• “Have there been any recent changes in your job, marital status, or insurance plans?”

Also, don’t just take one insurance card—ask for all of them. Patients often forget they’re still covered under a spouse’s or parent’s policy, which could affect the primary vs. secondary insurance order.

Check and record these key details for every plan:

• Effective dates
• Group numbers
• Coverage type
• Policyholder relationship

Be sure to document everything clearly in the patient’s chart, and flag the account for eligibility verification.

Pro Tip: Scan both sides of every patient insurance card into your EHR. The back usually includes critical info like payer contact details and instructions for coordinating benefits. This thing is key when determining which insurance is primary or secondary.

Step 2: Use the COB Rules to Determine the Primary Payer

Once you’ve gathered the patient’s insurance details, the next step is to apply the Coordination of Benefits (COB) rules. These are standard guidelines used by insurance companies to figure out which insurance is primary and which is secondary.

This step helps you as a healthcare provider avoid claim denials, billing delays, and confusion over who pays first.

If the Patient Has Two Employer-Sponsored Plans

The general rule is simple:

• The plan provided through the patient’s own employer is primary.
• The plan from a spouse’s employer is secondary.

Example:

Amanda works full-time and has insurance through her job. She’s also listed on her husband James’s plan.

→ Amanda’s plan is primary, and James’s is secondary.

This rule ensures that the plan covering the individual directly pays first—not one where the patient is just a dependent.

If a Dependent Child Is Covered by Both Parents

Here, the “birthday rule” usually applies:

• The parent whose birthday falls earlier in the calendar year (month and day, not year) has the primary plan.
• The other parent’s plan is secondary.

Example:

Parent A’s birthday is February 15.

Parent B’s birthday is July 9.

→ Parent A’s plan is primary.

This is a common industry rule. But some insurance companies may follow different methods, especially in divorce or court-ordered custody situations.

If the Parents Are Divorced or Separated

The COB rules shift slightly:

• If there’s a court order assigning health coverage, that parent’s plan is primary.
• If there’s no court order, the custodial parent’s plan is usually primary.
• If the custodial parent remarries, the step-parent’s plan becomes secondary, and the non-custodial parent’s plan becomes tertiary (third in line).

These rules ensure the correct plan pays first, reducing delays for providers and out-of-pocket surprises for patients.

When Medicare Is Involved

Medicare follows its own COB rules, which are governed by federal billing laws.

In these cases, it’s crucial to verify:

• Is Medicare the primary payer?
• Or is it secondary to a group or employer-sponsored plan?

Getting this right is essential to avoid denied claims and compliance issues with federal regulations.

Here are the most common Medicare scenarios:

Pro Tip: Never assume Medicare is automatically primary.

Step 3: The Secondary Insurance Becomes Clear

Once you’ve identified the primary insurance, the next step is easy—the secondary insurance is the other active plan the patient has.

The role of secondary insurance is to review what the primary plan has already paid, and then decide whether it will cover any remaining balance.

Secondary insurance often helps cover:

• Deductibles
• Co-insurance
• Co-pays
• Extra services not fully covered by the primary plan

But keep in mind that it’s not a guarantee of full coverage. The secondary plan will only pay up to the allowed amount based on its own policy rules. That’s where Coordination of Benefits (COB) comes in.

Example:

A $200 office visit is billed.

• The primary insurance pays $140, and applies the remaining $60 to the deductible.
• The secondary plan may pay some or all of that $60, depending on its coverage rules.

This helps patients lower out-of-pocket costs and helps healthcare providers collect full reimbursement for their medical services that they provide to their patient.

Step 4: Verify the patient’s COB Status with the Insurance Companies

Even when everything looks clear on paper, don’t stop there. Always verify the Coordination of Benefits (COB) status directly with the insurance companies.

Why? Because patient’s insurance information can change and this quick step can save you from billing headaches down the road.

As a healthcare provider, it’s your job (or your billing team’s job) to check which plan is officially listed as primary and which one is secondary for that specific patient—on that specific date of service.

You’re not just assuming, you’re confirming!

How to verify it:

You’ve got a few solid options:

• Use payer portals like Availity, or the insurance company’s direct system
• Check through a clearinghouse like Change Healthcare
• Or go the old-school route and call a payer rep on the phone

What to Ask the Rep:

When you get a payer rep on the line, ask clearly:

“Can you confirm whether this plan is primary or secondary for [patient’s name] as of [date of service]?”

This gives you a firm answer straight from the source and avoids errors due to outdated or missing info in your own system.

Don’t Forget to Document:

Always record the details of your verification:

• Name of the representative you spoke to
• The call reference number
• Date and time of the call
• Any notes about COB confirmation

This becomes your backup if a claim is ever questioned or denied.

Common Pitfalls to Avoid When Determining Primary vs. Secondary Insurance

Dealing with patients who have more than one insurance plan is pretty common stuff. Making sure you know which plan pays first is the key step. When that’s clear from the start, claims have a much better chance of going through cleanly. This really helps your office run smoother, and gives patients one less thing to worry about. Let’s walk through the usual mix-ups so you can spot them ahead of time.

Medicare Isn’t Always Primary

Yes, Medicare is often the primary payer. But there are key situations where it’s secondary instead. For example:

• The patient is still working and has a group health plan through an employer with 20 or more employees
• The patient is disabled and covered under a large group plan (100+ employees)
• The patient’s treatment is related to a workplace accident, and it’s covered by workers’ comp or liability insurance

In these cases, Medicare becomes the secondary payer, and the other insurance must be billed first.

Medicaid Is Never Primary

Unlike Medicare, Medicaid is governed by a strict federal rule: it is always the payer of last resort.

That means if a patient has any other form of insurance—whether it’s through an employer, spouse, or Medicare—you must bill that plan first. Medicaid only steps in after all other insurance options have been exhausted.

If you fail to do this, then your claim will almost certainly be denied.

Pro Tip: Always ask patients, “Are you still working?” and “Is your coverage through a current employer?”

Billing the Wrong Payer First

Even if you’ve gathered all the right info, billing the wrong insurance first can mess up everything. This is one of the most frustrating (and totally avoidable) issues for healthcare providers.

When you bill the incorrect payer—let’s say you guess wrong on which insurance is primary vs secondary—the claim will likely get denied. That denial means you now have to send it again to the correct payer, and the whole process starts over.

Pro Tip: Use electronic eligibility tools (e.g., Availity, clearinghouse portals) to verify COB before submitting claims. It’s faster than guessing.

Forgetting to Verify the Effective Dates of Each Policy

This one’s easy to miss. But it can cost you valuable time. Just because a patient shows a valid-looking insurance card doesn’t mean their coverage is still active. Insurance coverage isn’t always continuous. If a plan has expired or hasn’t started yet, and you bill it anyway, your medical claim is going to bounce back.

Here’s What Can Happen:

Let’s say a patient gives you a current insurance card. Everything looks fine and you bill the plan. But what you might not know is they changed jobs last month, and that plan might no longer be active.

As a result of this, you submit the claim only to get a denial. Now your team has to scramble to track down the new insurance info and resubmit the claim—and hope it’s not too late.

Pro Tip: Always confirm the effective start and end dates for every insurance policy—especially during eligibility checks. This is extra important at the start of the year, when many insurance plans renew, update, or switch altogether.

Not Asking Patients About Coverage Changes During Open Enrollment or Life Events

Here’s a pitfall that happens more often than you’d think: patients forget to mention their insurance has changed.

Why? It’s human nature. This kind of oversight is known as an “assumption trap”—people assume everything is fine and forget the details. They may not realize their update matters, or they think the process happens automatically.

This is especially common during:

• Open enrollment season
• Life changes like marriage, divorce, changing jobs, or turning 65 (and becoming eligible for Medicare)

If you don’t ask, they often won’t tell—until something goes wrong with their insurance claim.

Example:

A patient turns 65 and signs up for Medicare. But they don’t tell you, because they assume it “just kicks in.” So, you continue billing their employer-sponsored plan, not knowing Medicare should have been involved.

→ Result? The claim gets stuck. You’re left fixing a billing mess that could’ve been avoided with a quick question upfront.

Not Updating COB Can Lead to Costly Mistakes

Many providers make a common mistake: they don’t update the Coordination of Benefits (COB) each year. But COB status can change anytime, not just yearly — even mid-year.

Here’s why: employers often switch insurance carriers. Patients may change jobs. Parents may shift custody arrangements. If your system still uses old COB info, you’re likely billing the wrong plan. That means claim denials and unhappy patients.

For example: if a child’s custody changes mid-year but your EHR still lists the old parent’s insurance as primary, you’ll bill the wrong payer. The correct insurer then says, “We’re secondary,” and denies the claim.

This creates confusion about which insurance is primary and which is secondary. When a patient has two plans, it’s crucial to know how to determine primary vs secondary insurance to avoid billing issues.

Pro Tip: Always confirm and update COB at least once a year, and anytime a patient mentions new coverage. Better yet, flag patients with more than one plan in your EHR. Set reminders to review COB details regularly. This helps ensure you’re billing the correct primary insurance and avoids claim rejections.

Tools to Identify Primary and Secondary Insurance

With the right tools, your team can verify coverage orders in real time, catch COB issues before billing, and ensure claims are submitted correctly the first time. Let’s break them down by type and how they specifically help identify primary vs. secondary insurance.

Eligibility Verification Tools (Real-Time)

These are your first line of defense when verifying patient insurance. They pull live data from payers, including plan status, coverage order, and sometimes COB remarks.

Key platforms that provide these tools include: 

• Availity (for BCBS, Aetna, Humana, and more)
• Experian Health
• Office Ally
• Navinet (for Independence, AmeriHealth, etc.)
• Your clearinghouse portal (e.g., BellMedEx’s FusionEDI)

How do they help?

• Show the active vs. inactive status of policies
• Reveal if the plan is listed as primary or secondary
• Display COB indicators (like “COB on file,” “other coverage exists,” or “secondary to Medicare”)
• Include effective and termination dates for each plan

Insurance Company Portals (Direct Payer Access)

Logging into each payer’s official provider portal gives you the most accurate and updated COB details—especially for complex cases.

These insurance company portals are:

• UnitedHealthcare Provider Portal
• Cigna for Health Care Professionals
• Aetna Payer Space
• Blue Cross Blue Shield portals (via Availity or direct login)
• Medicare MAC portals (Noridian, Novitas, etc.)

How do they help?

• View plan hierarchy when multiple policies exist
• See which plan is listed as primary in the insurer’s system
• Often provide member plan history and previous COB notes
• May include recent COB questionnaires submitted by patients

Clearinghouses

Clearinghouses act as intermediaries between your EHR and payers. Many have built-in tools for identifying primary and secondary coverage during pre-claim.

Common Clearinghouses are:

• TriZetto (now part of Waystar)
• BellMedEx Clearinghouse
• Change Healthcare
• Office Ally
• Claim. MD

How do they help:

• Show payer response messages that indicate COB issues or mismatches
• Let you run batch eligibility checks for patients with dual coverage
• Provide denial codes and explanations that signal incorrect payer order (e.g., “this plan is secondary to another policy”)

Patient Intake & EHR Tools

Never underestimate the power of your intake process and EHR system to help identify primary and secondary insurance — when used correctly.

These EHRs and patient intake tools include:

• Luma Health
• Mend
• Medifusion by BellMedEx
• Florence
• SolutionReach
• IntakeQ

How do they help?

• Some EHRs (e.g., Epic, Athenahealth, Kareo) offer custom insurance fields to mark payer order
• Intake forms can be set to prompt patients about other coverage, Medicare status, or recent insurance changes
• Patient self-check-in kiosks and portals can be used to update COB info digitally

CAQH (Council for Affordable Quality Healthcare)

Though CAQH is primarily for medical credentialing, many payers sync COB and provider data. It helps keep your practice’s information accurate, which impacts how claims are processed.

CAQH helps identify insurance using:

• CAQH ProView
• Payor portals

 How it helps:

• Keeps your practice’s data in sync across multiple payers
• Some patients’ COB data gets stored/updated through CAQH
• Ensures payer systems recognize you correctly as a participating provider for both plans (impacts COB logic)

Coordination of Benefits Questionnaires (Direct from Payers or Patients)

Sometimes, the best way to determine an insurance order is straight from the source: the patient.

Most insurance companies send COB questionnaires when they detect multiple coverages. If unanswered, this can pause claims or delay processing.

A Coordination of Benefits (COB) Questionnaire is typically used to gather information about a patient’s multiple insurance policies to determine which insurance plan should be billed first (primary) and which will be billed second (secondary).

Healthcare providers and insurance companies often use these questionnaires to ensure that claims are processed correctly and that the right plan is responsible for the payment.

Here’s a list of common questions you might find on a COB Questionnaire:

Primary Insurance Information:

• What is the name of the primary insurance carrier?
• What is the policy number of the primary insurance plan?
• Is the primary insurance policy under the patient’s name or someone else’s (e.g., spouse or parent)?

Secondary Insurance Information:

• Do you have secondary insurance coverage? (Yes/No)
• What is the name of the secondary insurance carrier?
• What is the policy number of the secondary insurance plan?

Relationship to the Insured:

• What is your relationship to the primary policyholder? (e.g., self, spouse, child, etc.)
• If not the primary policyholder, who is? (Name and relationship)

Employment-Related Insurance:

• Does an insurance plan cover you through your employer? (Yes/No)
• If yes, provide the employer’s name and your group number.
• Does your spouse or another family member have employment-based insurance? (Yes/No)

Medicare Information (if applicable):

• Are you enrolled in Medicare? (Yes/No)
• Is Medicare your primary insurance? (Yes/No)
• What is your Medicare number?

Coverage for Dependents:

• Does another insurance plan cover any of your dependents? (Yes/No)
• If yes, provide the details (name, policyholder, policy number).
• Changes in Coverage:
• Have there been any recent changes to your insurance coverage? (Yes/No)
• If yes, provide details (e.g., change in policyholder, employment status, etc.).

Other Health Coverage:

• Do you or your family members have other health coverage not listed above? (Yes/No)
• If yes, provide details about the other health coverage.
• Coordination of Benefits Confirmation:
• Do you understand the coordination of the benefits process? (Yes/No)
• Have you provided accurate and complete information regarding your insurance coverage? (Yes/No)

Final Thoughts

Understanding which plan is primary might seem difficult initially, but with a consistent system and precise knowledge of the rules, it becomes much more manageable.

Always focus on the relationship to the policy, the employment situation, and whether government programs are involved.

When in doubt, ask detailed questions, document everything, and use online tools when available.

Training your staff to follow a reliable process will reduce claim errors, avoid payment delays, and offer better patient service.

While write-offs can sometimes be an agreed-upon reduction, they can also lead to bad debt and significant revenue loss if not managed correctly. This article breaks down what write-offs are, how they differ from adjustments, when to write off a claim, and how to avoid unapproved or unnecessary write-offs.

One quick thing; we know that effective provider write-offs and precise claim management are important. That’s why, we help you manage them with our expert medical billing RCM specialists. Get free consultation with us to learn how.

What is Provider Write Off in Medical Billing?

A provider write-off in medical billing is the portion of a billed charge that a healthcare provider decides not to collect, either from the patient or insurance company. It occurs when a provider is unable to collect the full amount for a service rendered, usually due to agreements with insurance companies, legal requirements, or internal policies.

Write-offs are important for maintaining accurate financial records and ensuring compliance with various contractual or regulatory standards. Instead of continuing to pursue payment for these uncollectible amounts, providers “write them off” as unpayable.

For example, if a healthcare provider charges $700 for a procedure, but the insurance company’s contract stipulates a payment of only $500, the $200 difference is written off as a contractual adjustment. This is a common form of write-off that happens in healthcare. Another example could be when a patient’s balance is too small to justify collection efforts.

Major Types of Provider Write Offs

Here are some examples of provider’s write offs:

• Contractual Write-Offs
• Bad Debt Write-Offs
• Charity Care Write-Offs
• Small Balance Write-Offs
• No Insurance Write-Offs
• Promotional Write-Offs
• Timely Filing Write-Offs
• Uncredentialed Write-Offs

➜ Approved or Necessary Write-Offs

These write-offs are unavoidable and are part of the financial policies or contractual agreements between the provider and the payer.

Contractual Write-Offs

Contractual write-offs are necessary when a healthcare provider agrees to accept a lower payment from an insurance company than what was billed. This write-off is due to the allowable fee set by the payer, as per the terms of the contract.

For example, if a provider bills $1,000 for a service but the insurer’s contract allows only $700, the $300 difference is written off.

Charity Write-Offs

Charity write-offs are offered when a provider forgives a portion or the entire bill for patients who cannot afford to pay. This usually occurs when the patient qualifies for a financial assistance program due to their low income. These write-offs reflect the provider’s commitment to serving the community.

Small Balance Write-Offs

Small balance write-offs occur when the outstanding amount is too small to justify the administrative effort of billing or collection. For example, if a patient owes $12, the provider may choose to write off the balance rather than spending time and resources to collect it.

These write-offs are commonly seen when the amount is under $15 or $20, and the provider may add it to a future visit or simply let it go.

Promotional Write-Offs

Promotional write-offs are offered to encourage patients to pay in full at the time of service. This is common for self-pay patients who do not have insurance. For example, if patients paying out of pocket agree to pay in full during their visit, doctors might offer a discount or reduce the bill.

➜ Unnecessary Write-Offs

Unnecessary write-offs are avoidable and occur due to errors or inefficiencies in the billing process and are avoidable.

Timely Filing Write-Offs

Timely filing write-offs occur when claims are submitted after the payer’s deadline. Each insurer has specific filing timeframes, such as Medicare requiring claims to be filed within 12 months. If your practice misses these deadlines, you may have to write off the charges.

To avoid this, track claim submission deadlines carefully and set reminders to ensure timely filings for each payer.

Uncredentialed Provider Write-Offs

Uncredentialed provider write-offs happen when claims are filed for a provider who isn’t yet credentialed with the insurance company. This results in a denial of the claim and a write-off of the amount.

To avoid this, always verify the provider’s credentialing status with the payer before providing services. If needed, inform patients about non-covered services or self-pay options in advance.

Administrative Write-Offs

Administrative write-offs are granted when mistakes occur in the practice, such as when a provider mistakenly tells a patient that they are in-network with their insurance, but they are not. These situations may result in the practice writing off the charges as a courtesy.

To minimize these errors, ensure your team is well-trained on insurance verification and communicate clearly with patients about in-network and out-of-network status.

Collection Agency Write-Offs

Collection agency write-offs occur when unpaid balances are transferred to a third-party agency. These amounts are no longer pursued by the provider but are instead handled by the collection agency. However, they should not be forgotten entirely.

Monitor accounts with unpaid balances and only schedule new appointments after patients agree to a payment plan.

Bad Debt Write-Offs

Bad debt write-offs occur when a provider chooses not to pursue payment from a patient or insurance company due to unsuccessful collection efforts. This usually happens after several attempts to collect payments have failed.

To reduce bad debt, ensure your practice follows up on outstanding balances, verifies insurance coverage before services are rendered, and offers payment plans when necessary.

How to Avoid Unnecessary Write Offs

Avoiding unnecessary write-offs can significantly improve your practice’s bottom line.

Here are effective strategies to minimize revenue loss.

1. Use Reporting and Analytics Tools

Take advantage of medical billing software with built-in analytics. These tools can spot trends and areas where you’re losing money, allowing you to act before write-offs happen.

2. Conduct Regular Audits

Perform internal audits to identify any recurring issues, such as incorrect coding or billing mistakes. By catching these errors early, you can avoid unnecessary write-offs.

3. Train Your Staff

Ongoing training for your billing and coding team is essential. Ensure they understand the latest industry regulations and know the correct procedures to follow. Well-trained staff make fewer errors, which reduces write-offs.

4. Stay Compliant

To prevent denials and bad debts, make sure to follow all payer requirements, including insurance verification, pre-authorizations, and timely claims submission. Compliance with these rules is key to avoiding unnecessary write-offs.

Can Doctors Write Off Unpaid Bills?

Yes, doctors can write off unpaid bills, but the process and reasons behind it vary based on the situation and the policies of the medical practice. There are several scenarios where write-offs may be appropriate, for example, bad debt, charity care, small balance, etc.

But you must take care of these points, when writing off unpaid bills:

• Ensure that write-offs are well-documented and compliant with internal policies.
• Constantly monitor unpaid bills and analyze patterns to minimize future write-offs.
• Adhere to IRS guidelines for bad debt deductions while maintaining efficient billing practices to minimize unnecessary write-offs.

Can a Provider Write Off a Deductible?

Providers cannot write off deductibles because these amounts are parts of the patient’s financial responsibility. Writing off deductibles, copayments, or coinsurance can violate insurance contracts and may lead to contract termination, HIPAA violations, or even charges of fraud. It can also run afoul of the federal Anti-Kickback Statute (AKS), which is a felony.

But there are limited exceptions where providers might waive fees, such as in hardship cases or charity care. Even so, the decision to lower or remove a copay or deductible must be made for each case separately and cannot be done regularly.

Always, consult with an attorney or a billing specialist like BellMedEx to understand the specific rules and regulations that apply to your situation. Speak to our medical billing specialist now.

When Can You Write Off Medical Bills?

You can write off medical bills on your taxes if they exceed 7.5% of your adjusted gross income (AGI) and you itemize your deductions on Schedule A (Form 1040). This includes payments for diagnosis, treatment, prevention, and other medical care expenses that aren’t reimbursed by insurance.

🛈 How to Properly Write Off Medical Bills as a Provider?

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Let us share quick, actionable steps on how to rightly write off as a provider.

1. Identify Eligible Write-offs

• Review the claim to determine if it qualifies for a write-off.
• Look for reasons like insurance denials, patient financial hardship, or billing errors.
• Assess if the bill is uncollectible due to coverage limits or patient circumstances.

2. Document the Reasoning

• Keep detailed records of why you are writing off the bill.
• Note if it’s due to a payer’s denial, a patient’s inability to pay, or a contract issue.
• Ensure you document any supporting evidence like financial hardship applications or denial letters.

3. Follow Internal Policies

• Establish clear guidelines for when and how to write off claims.
• Ensure your policies are consistent with legal and ethical standards.
• Review your policies regularly to prevent unnecessary write-offs.

4. Make Timely Write-offs

• Once eligibility is determined, write off the claim immediately.
• Enter the write-off in your general ledger to avoid confusion later.
• Promptly mark unpaid claims as “not to be pursued” for future follow-ups.

5. Review and Audit Regularly

• Periodically audit your revenue cycle to identify trends in write-offs.
• Review your practice’s financial health to ensure you’re not overusing write-offs.
• Retrain your billing staff as needed to maintain accuracy and efficiency in the process.

As a healthcare worker, you work really hard to help patients get the care they need. So getting paid for that care should be easy. But when claims aren’t filed on time, that’s exactly what happens. Denials pile up, revenue drops, and you’re left with a mountain of paperwork and rejection letters.

The good news? Filing claims on time doesn’t have to be a struggle! Insurance companies give you anywhere from 30 to 180 days to submit claims after the date of service. Some let you have up to a year or even longer. That’s plenty of wiggle room.

This article will be your timely filing roadmap. Let’s go over the basic filing limits for major insurance plans. You’ll find out how to avoid mistakes that slow down your claims. We’ll give you great tips to help you meet all your deadlines, every single time!

Stay with us, and you won’t miss any more cutoffs! Your reimbursements will go through easily. Your days of denial and deferred revenue will be over. Imagine this—you can use that saved time and money for what really counts: your patients.

First, let’s discuss what timely filing is in healthcare.

What is Timely Filing in Healthcare?

Timely filing refers to the specific timeframe within which healthcare providers must submit claims to insurance companies for the services they’ve provided. It’s essentially a deadline for filing claims. If providers fail to submit their claims within this predefined timely filing limit, the insurance companies will deny the claims, and the providers won’t get paid for the care they’ve given to patients covered by that insurance plan.

Additionally, the timely filing term also applies to the timeframe providers have to submit appeals for any denied claims. Some insurance companies set the same timely filing limits for both initial claims and appeals for denied claims.

How to Easily Find Timely Filing Limits?

Don’t stress about locating timely filing limits for insurance claims. We’ve got you covered with a valuable guide that clearly outlines the timely filing limits for various insurance providers. Save time and effort by referring to our comprehensive resource.

Timely Filing Limits of Different Insurance Companies

The table below shows the timely filing limits for different healthcare insurance companies in the USA. These include Aetna, Ambetter, AvMed, Anthem, Beacon Health, Caresource, Champus, Cigna, Fidelis New York, GEHA, Humana, Kaiser Permanente, Magellan, McLaren Health Plan, Medicare, Medicaid, and United Healthcare.

*Keep in mind that these time frames can vary based on the state where the insurer operates. Many payers offer consistent time limits for denied claims, but we recommend checking their official websites for the most up-to-date information on denied claim filing deadlines.

Timely Filing Limit for BCBS (Blue Cross Blue Shield) in Different States

Explore the timely claim filing limits for BCBS in different states with our user-friendly guide. Plan ahead and make sure that claims are sent in on time so that reimbursements proceed smoothly.

The Importance of Timely Filing Limits for Healthcare Providers

It’s really important for healthcare providers in the United States to submit insurance claims on time. Filing on time might feel monotonous, but it can really help improve your medical practice’s bottom line. Here’s why it’s so important:

Speedy Reimbursement

The sooner you submit a claim, the sooner you’ll receive reimbursement. This improves cash flow, allowing you to cover overhead and pay employees and vendors on schedule. Fast reimbursements also let you spend more time taking care of patients instead of worrying about chasing payments.

Higher Acceptance Rates

Insurance companies are much more likely to pay claims if you submit them on time. After the deadline passes, they may outright deny the claim or reimburse at a lower rate. Submitting on time avoids these issues.

Fewer Hassles

Submitting late can lead to lengthy appeals and other headaches. You’ll waste time resubmitting forms and records. It gets really annoying for both the doctors and the patients. Filing on time stops these issues from happening.

Compliance

Insurance contracts require filing within a certain window, often 90-180 days from the date of service. If you file too late, it breaks this agreement. This might hurt your relationship with payers or could even cause audits later on.

More Revenue

Filing on time means you get paid more and earn more money for your practice. It helps money keep coming in and makes things easier to manage. This lets you concentrate on giving great care. Setting reminders, automating payments, and following good habits can help you meet your filing deadlines every time.

Smart Ways to File Insurance Claims on Time and Avoid Denials

When insurance claims get denied, it can really stress out healthcare workers. It makes them frustrated, slows down payments, and can even cost money. If you use some smart tips, you can make filing claims easier, send them in on time, and reduce the chances of getting denied. Let’s jump into some great tips that can help you save time and money!

Get to Know Payer Guidelines Really Well

First, you need to know the rules and deadlines for each payer really well. These can be really different depending on where you live and which insurance company you choose. Keep track of these rules and any special cases or extra time they might give you. It’s really important to know the road rules so you can avoid problems later on.

Automate and Streamline the Submission Process

Filing claims by hand can lead to mistakes and take longer than it should. Use technology to make things easier! Automate everything you can, like coding, patient treatment claim submission, and following up. Use billing software that finds errors, makes clear claims, and sends them out electronically. Make clear deadlines for your team and help everyone stick to the rules all the time.

Prioritize Accuracy and Completeness

A small mistake or missing detail can mess up a claim. Teach the staff well about how to code and write down what they do so everyone understands the services provided. Make sure to have a strong quality check with different steps before you hit submit. Transmit supporting documentation electronically to expedite processing.

Talk to Payers Early and Often

Talk to insurance companies right from the start. If problems come up, you can easily find ways to fix them fast. Be responsive to any inquiries or requests for more information from payers.

Verify Patient Details Upfront

Wrong or outdated patient insurance information is a big reason why claims get denied. Confirm the patient’s plan enrollment, coverage details, and filing requirements before rendering services. Update records proactively to reflect any changes.

Persistently Follow Up on Denials

Denials happen, but don’t just accept them at face value. Look at why denials happen, figure out the main reasons, and make sure you have a clear way to appeal and send things back in. Keep checking in to lower that denial rate!

Get Paid Fast with BellMedEx Claim Filing Services

Are you having a hard time with claims getting denied and waiting a long time for your money back? Outsource your claim filing to BellMedEx and get paid faster. Our skilled billing team makes sure your claims are sent in correctly and on time, so you get paid back as fast as possible. Plus, BellMedEx provides full revenue cycle management, coding, auditing and legal services to address any issues. Join forces with BellMedEx today and stop wasting time waiting for payments.

Schedule Free Consultation Now

Well, you’re not alone!

The medical billing process can be really confusing for anyone, even doctors and nurses. At first, it might take some effort to figure out how it all works. Sometimes, you might even need help from an expert if you get stuck.

That’s where MEDICAL BILLING ADVOCATES come in.

These are people who are there to help patients like you and me. They make sure we understand our medical bills and can sort out any issues we have with insurance companies.

Below is a detailed guide to help you understand medical billing advocates more.

Who is a Medical Billing Advocate?

Medical billing advocates are professionals who help patients understand and deal with medical bills. Basically, they make medical bills easier to understand for patients. Here is what they do:

➜ First, they carefully check medical bills to make sure they are correct. They look for any mistakes or unfair charges along the way.

➜ Next, they talk to insurance companies about lowering the amount patients have to pay. They try really hard to get the best deal for patients.

➜ Also, they explain insurance policies and medical billing rules in simple terms. Things like copays and deductibles can be so confusing. Advocates break it down step by step so it’s easy to understand.

➜ Finally, they happily answer any questions patients have about their medical bills. Patients can feel totally lost trying to deal with complicated bills. Advocates kindly guide them through the process.

Medical Billing Advocates often work independently and charge patients a small fee. Their job is to take the stress out of medical billing. They make sure patients pay the right amount and understand what they are paying for.

8 Benefits of Hiring a Medical Billing Advocate

Medical billing advocates can help you (i.e the patients) in many ways.

They Are Experts In Medical Billing

First of all, they are experts in medical billing and insurance. This means they know all about medical codes, insurance terms, and billing practices. So if there are any mistakes in your medical bills or if you are overcharged, they can spot these errors and fix them.

They Can Save You Money

Another big benefit of using medical billing advocates is that they can save you a lot of money. For example, by checking your medical bills for errors, they can make sure you don’t pay more than you should. Also, they can negotiate with insurance companies to get you discounts.

They Help with Insurance Claims

What’s more, if your insurance claim is denied, medical billing advocates can help you appeal it. They will help you prepare and submit all the necessary documents to the insurance company. Plus, if you have any misunderstandings about your insurance plan, they can clear those up for you. They will also check if your claim should have been covered under your plan or not.

They Save Time and Reduce Stress

Lastly, dealing with medical bills and payment disputes can be really time-consuming and stressful, especially if you’ve just been sick. That’s why hiring a medical billing advocate is a good idea. They will handle all the communication with hospitals, doctors, and insurance companies for you. This saves you a lot of time and stress.

They Provide Personalized Support

Medical billing advocates take the time to understand the patient’s specific medical situation and financial capacity. Then, they create a custom action plan according to the patient’s needs and ensure avoiding any financial burden.

They Have Knowledge of Consumer Protection Laws

In addition, advocates know the consumer protection laws related to medical billing and save you from illegal practices like surprise billing or balance billing. For example, surprise billing is when you take services from an out of network doctor and you’re charged for the difference between what the insurance pays and the provider’s charges.

They Assist with Out-of-Network Issues

Furthermore, if you’ve received services from an out-of-network provider the billing advocate would help you understand the financial responsibility. They will also work on negotiating a lower rate with the healthcare provider or insurance company.

They Provide a Learning Opportunity

Finally, while working with a medical billing advocate you can learn all the ins and outs of the medical billing and insurance claims. Once your knowledge and understanding is improved you’ll be making better choices in the future saving you time, effort and money.

Best Ways to Find a Medical Billing Advocate

Do you need help with your medical bills? Finding a medical billing advocate can make things easier. But how do you find one? Let me tell you the best ways.

Professional Organizations

First, there are special groups that have lists of certified medical billing advocates. You can look at their lists and find someone good. Some of these groups are:

• American Medical Billing Association (AMBA)
• National Association of Healthcare Advocacy (NAHAC)
• The Alliance of Claim Assistance Professionals (ACAP)

Referrals

Next, you can ask people you know for suggestions. Talk to your doctor, insurance company, or even friends and family. They may know a great advocate. Asking people who have used an advocate before can help you make a good choice.

Online Search

Finally, you can search online for medical billing advocates near you. Many websites let you read reviews from other people. Just be sure to pick someone with lots of good reviews and fair prices.

FAQs

Are advocates for medical billing expensive?

Most individuals could afford them. Their billing approach affects their fees. For instance, should a medical billing advocate charge hourly, the fees could run from $75 to $350 per hour. Conversely, should they charge based on the money you save, the charges might be between 25% and 35% of the total saved.

What information do medical billing advocates need?

Medical billing advocates may request the following from you:

• Personal Information Details About Health Insurance
• Medical Bills
• Signed Authorization Form
• Medical Notes (should necessary)
• Payment Transcripts

Does every medical bill issue require hiring a Medical Billing Advocate?

No. By calling your insurance company or healthcare provider, you may fix basic medical billing problems on your own. You basically need someone to advocate for difficult problems, large costs, or when you lack time or information to handle things on your own.