CMS 1500

Medicare is implementing a three year Pre-Claim Review Demonstration of Home Health Services in the states of Illinois, Florida, and Texas beginning in 2016, and in the states of Michigan and Massachusetts beginning in 2017.  CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits.

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During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies.  It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the lifeblood for practice survival.

Claims Processing (Resource 199)

A properly completed claim (whether paper or electronic) is a critical component of the reimbursement process. A clean claim is vital to the processing and payment of your claims. The "cleaner" the claim, the faster you will receive payment. It is the responsibility of the provider to understand what is needed and required by the carrier, then provide that information in the specified manner and time frame.

You need to understand the following concepts:

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