Frequently Asked Questions for Providers

FMBS 2016 Changes
Contract
1. Accounts NOT paid within 10 days of invoice receipt will result in your account being suspended until payment in full is received. Verifications paid by patients will not be affected by account suspension.

2. Facilities billed and paid to the patients that are NOT signed over to the provider will access a $50.00 submission fee.

Verifications
1. Verifications for NON contracted providers will list the deductible dollar amount/the coinsurance percentage that you, the provider, will base off your charge amount and the total due to collect.

Staff Introduction
1. Lloyd Hopkins will be moving into the role of Vice President. Lloyd will be reaching out to each provider individually to introduce himself.
His duties will consist of:
  • Reporting
  • All provider relations that is NOT directly related to verifications and claims submitted by the provider or patient

  • 2. New staff now consists of benefit verifications/payment posting and claim research.
    **I will be using this freed up time to research current and more lucrative billing opportunities for my providers and their practice.

    Education and Consulting
    1. During the Spring of 2016, FMBS will offering weekly interactive workshops
  • Workshop titles and times will be provided
  • 2. Guidance outside of the services FMBS has been contracted to provide for your practice will need to be discussed under FMBS consulting services * Fee May Vary

    Valid Appeals
    1. Claims that are paid at less than 80% of billed charge will be appealed 1st level ONLY

    2. Denied authorizations will be appealed first level with the assistance of the patient, due to enforced insurance guidelines

    3. Recoupment request from the insurance will be appealed once the following has been provided to and received by FMBS:
  • Insurance Recoup letter
  • Any requested pertinent information to write a valid appeal

  • Provider Patient Disputes
    1. FMBS will no longer handle disputes between patients and providers regarding patient balances and contracts. FMBS will continue to assist and answer questions directly related with claims submitted by FMBS as well as verifications. In the even you have a non-paying client, FMBS can assist in sending patients to an outside collection agency.

    2. IT is important that your contracts:
  • Provide clear financial expectation regardless of insurance payments
  • Inform patients that due to your network status verification and insurance, payments are not guaranteed, but only an estimate
  • Specifies that based on what services are billed and covered can affect both verification provided and the payment made from the insurance


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    1. Do you negotiate contracts on behalf of clients? What is your process in doing so?

    ** Please note that we cannot accept any proposals based off the Medicare fee schedule or carving out of codes as systematically we are prohibited from doing them. On company letterhead, please follow the below steps.

  • 1) The Provider would submit a written request (either via certified mail or E-mail) outlining why an increase is requested. Within the letter, include the percentage of the fee schedule you would like to receive along with any additional information that would help demonstrate what sets yourself apart from other providers within your specialty. This also supports your requests for a non-standard reimbursement rate. Please also indicate any special services that your provide that your peer s may not, along with the CPT codes. Also, explain what steps you have taken to control costs within your practice with examples to support this.
  • 2) Once we get the request it is logged into the system and you would then receive an acknowledgement letter advising it could take anywhere from 8-10 weeks for a determination.
  • 3) Once reviewed the request is approved, pended for additional information, or denied.

  • For 3rd party OON contracts, FMBS rejects the request to settle OR negotiate as these contract types requires a discount of billed charges and eliminates the opportunity to balance bill (practice option)

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    2. One person assigned to account? What if they are on vacation or sick?
    FMBS believes in cross training in all areas of its business. FMBS does not assign accounts to any singular person. Currently, Kashuna handles all provider/ patient correspondence.

    Vacation times are provided (unless emergent) at least 2 weeks in advance to all providers. Patients are notified upon contact via email auto reply or phone message.

    Claims are NOT effected by vacation or time off, as they are sent out daily.

    All other correspondence and replies are returned upon return to the office (based on out of office time frame). Correspondence during out of office longer than a week will have "timed window" response.

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    3. Can I have a reference list for your services?
    Please see a list of references you are free to contact.

    Complete Billing and Collections
    Blossom Birth and Wellness Center, Arizona, Mary or Nichelle
    blossombirthcenter@gmail.com

    Complete Billing
    New Beginnings Birth Center, Idaho, Kyle
    nbbplace@gmail.com

    Misty Andriennse Midwifery, California, Misty
    520.603.9197

    Complete Billing and Consulting
    Authentic Birth, Tony
    tonyskarlatos@gmail.com

    Thrive Birth Center INC
    Makenzie Burt
    makenzie@thrivebirth.com

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    4. What insurance carriers are you dealing with?
    FMBS deals will ALL insurance carriers both commercial and Medicaid for current client states as well as Medishare policies.

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    5. What are your fees for?

  • Self-pay
  • State Medicaid clients
  • State Medicaid clients administered by third party
  • Private insurance clients

  • FMBS offers a three option service reimbursement

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    6. What are fees based on: Amount billed? Amount reimbursed/recovered?
    1. FMBS 6% fee

  • a. Based on all amounts collected by FMBS from both patient and clients.

  • 2. Flat fee per provider claim. facility claim billed without benefit verification at the patient cost
  • a. 85.00 for all maternity related provider claims (CPT 59400 / 59425/59426)
  • b. 35.00 for all other care NOT provided at time of delivery billing
  • c. 350.00 for all paid facility claims (this amount is sometimes lowered based on paid amount)

  • 3. Flat fee per provider claim. facility claim billed with benefit verification at the patient cost
  • a. 110.00 for all maternity related provider claims (CPT 59400 / 59425/59426)
  • b. 35.00 for all other care NOT provided at time of delivery billing
  • c. 350.00 for all paid facility claims (this amount is sometimes lowered based on paid amount)

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    7.Track by client what all the billings/reimbursements for? Excel spreadsheet?
    FMBS provides the following monthly reports, at the end of each month OR within the first week of the next based on when the month ends and begins:

    Claims List that provides a list of all claims sent within the prior month (PDF)

    Accounts receivable list that provides all monies posted to each account within the prior month (PDF)

    Aging report that provides a list of current outstanding claims with notes on status. FMBS upon encountering a rejecting or insurance request will NOT wait until the aging report is due to communicate these things.

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    8. When charged the fee: When received or when billed?
    FMBS invoices are sent the last Friday of each month for services provided that month and are due within 7 days per FMBS contract

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    9. When bill the carrier: By encounter? Globally at the end of L&D? Post partum?
    Billing depends on contract status and timely limitation based on the plan.

    If OON then claims can be submitted once PP is complete as you have a year from date of care to send claims for payment.

    Because FMBS is a billing company that handle multiple providers and facilities. In order to streamline and justify billing charges FMBS uses Medicare rates and increases them by 300%(the legal max). Please understand that FMBS charges billed to insurance may or may not be in line with your previous charges.

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    10. What is your experience billing for birth centers/midwifery services?
    FMBS has been established since 2011 specializing in OB and Midwifery service.

    Kashuna has 15 years of medical billing with 8 in OB/GYN

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    11. What other fees are charged to us by you?
    FMBS only charges fees for billing services provided.

    Other services separate from billing can also be provided. Those prices are listed on the FMBS website under Prices and Services

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    12. Describe interaction between your person and me: Daily/weekly/monthly when reports issued/or as needed?
    Communication between FMBS and their clients are on an as needed basis but we are available by phone at 623-322-0730 OR email at info@favoredmedicalbilling.com

    FMBS does provide monthly reports and will make contact prior to providing your monthly reports for collections concerns

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    13. How soon expect a response to email or phone call?
    FMBS returns all correspondence within 48 hours, unless the correspondence was received on Friday, the weekend OR national holidays which in that case correspondence will be returned the next working business day

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    14. Do you do member verification? Is there a charge to do this?
    There is a charge for this. The charge can either be at the cost of the client OR the cost of the patient as outlined above under FMBS charged fees

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    15. Do you provide a printout that I can supply clients with explaining member coverage?
    FMBS provides a link from the website that the patient completes and is emailed to staff at FMBS. Once received a verification is performed and the response is emailed to the client with the facility CC'd on the email. The email can be printed out and added as part of the clients chart.

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    16. Do you issue billing statements to clients who owe money?
    FMBS can issue electronic statements. FMBS does NOT issue paper statements as they are expensive to supply and less effective. FMBS encourages upfront collections.

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    17. Do you take phone calls from clients if they have a question on benefits letter?
    FMBS does take patient calls as well as provide a FAQ on the FMBS website.

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    18. What is the process to change companies?
    How long does it take?
    The process takes however long the clients see fit to avoid as much "interruption" to their practice as possible. FMBS requests that account takeover is done on the 1st of any month desired by the client. This provides a clear date of accounting responsibilities. After the contract has been completed and requested documents received, the new client information is added to the FMBS billing system and claims can then be submitted.

    What is required of me?
    FMBS requires a signed contract and credentialing documents

    Fee charged to change
    FMBS does NOT charge a set up OR cancellation fee. In the event you wish to terminate your services with FMBS a 30 day written notice is required.

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    19. What are your expectations of the birth center?
    To return emails and phone calls within a reasonable timeframe

    Pay invoices within 7 days of receipt

    Communicate changes, gratitude and reasonable expectations

    Maintain open lines of communication between FMBS and birth center

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    20. Do you work with electronic medical record software i.e. Maternity Neighborhood or ClientCare?
    FMBS has worked with Maternity Neighborhood, Private Practice, Office Ally, Practice Fusion and Mobile Midwife. Most providers create a user and password for FMBS to utilize to retrieve medical records and other patient demographic information

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    21. How do you retrieve information to submit claims to insurance companies?
    FMBS requires that all providers complete and submit a custom superbill for services rendered on the FMBS website.

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    22. How often do you follow-up on denials? How often is follow-up done? Does it ever escalate to higher person in your organization to get involved? Is it dependent on dollar amount involved?
    FMBS handles rejected and denied claims on 2 occasions. Upon receipt of a rejected or denied communication from insurance and during account/aging review

    Appeals are sent whenever the claim is under paid based on the fee schedule for in-network providers. For out of network providers any claims paid under 80% of billed charges will be appealed to request how payment was determined since there is no fee schedule to follow and appeals are handled based on denial reason as they will vary per plan and plan benefit

    Main insurers for BBBC:
  • Medicaid – State 23%
  • Medicaid – RMHP 23%
  • Self Pay 25%
  • BCBS 15%
  • United HealthCare, Cigna, Humana 7%
  • Tricare 7%
  • Private insurance clients may increase with recent contract with new carrier (RMHP).

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    23. Claim Status, Appealed Claims, and Authorization Status
    Claims Submission
    Claims are submitted to insurance within 48 hours of receipt
    Receipt verification to insurance one week from bill date
    IF the system rejects the claim for any reason, an email will be sent with a copy of the rejection for resolution

    Claim Processing
    Claims are submitted electronically but insurance can still take up to 30 business day to process and make payment

    Claim Payment
    Payment nor any correspondence is sent directly to FMBS. Please make sure that each insurance company has the correct address.

    Claim Status
    Claim status is completed on a 6 week rotation. You can check the status of your office claims anytime using the online link under the provider portal

    Appealed Claims:
    Appeal submission within one week of processed claim
    Receipt verification to insurance one week from appeal sent date
    Appeal follow-up 40 days after insurance receipt
    *most insurance companies take 45 business days for appeal processing

    Authorization Status:
    Request sent within 48 hours of FMBS receipt
    Receipt verification of request and records one week from bill date
    *most insurance companies take 14 business days for authorization/nurse review request

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    24. Why shouldn't I settle?
    Although the request sent by 3rd parties on behalf of the insurance looks like a great deal, it usually is NOT! (hardly ever….Never) When you settle, you are agreeing to a discount off of the billed charge amount. But that is not what will be paid. From the amount they state they will pay, any patient responsibility will be deducted, and then a check will be cut. In addition, signing those agreements can also bind you to 'innetwork" processing, meaning the amount collected from your patient prior to claim processing may be inappropriate.

    MY Suggestion:
  • Request that the "allowed amount" is 80% of the billed charge so patient responsibility can be taken from that amount.
  • Request that they provide you the EXACT amount of your payout.

  • In the event they cannot do either of the two, request that the claim be sent back to the plan for processing.
    Without knowing the exact payout, it is difficult to know how the claim will process and pay, so there certainly is a risk to declining the offer. So please take into consideration my advice from my experience, but please always do what you feel is best for your practice.

    Example of how it is processed:
    They take billed charge $5,000.00
    Take discount 20%: $1,000.00 = $4,000.00 (allowed amount)
    Take patient responsibility Deductible / Coinsurance: $3,000.00 = $1,000.00
    Then pay the provider $1,000.00

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    25. What is Next & What to Expect
    PRIOR TO YOUR BIRTH/DELIVERY
    If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.

    https://www.favoredmedicalbilling.com/verifymybenefits.php

    *IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
    *IF you already have your benefits, PLEASE do not complete the form attached to the above link.

    AFTER YOUR DELIVERY
    Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.

    https://www.favoredmedicalbilling.com/ClaimSubmissions.html

    *Select Midwife Services

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    26. Midwife VS Hospital
    I recently had the pleasure of viewing a hospital bill for a vaginal delivery in the hospital and WOW! I was first shocked to see that the hospital bills for EVERYTHING, like aspirin, yes Bayer aspirin, has a pricey tag of 17.00! Overall, the hospital bill for a 24 hour stay was 8,000.00. This did NOT include the bill from the OBGYN that delivered the baby, the anesthesiologist, and finally, the doctors that made rounds. This quickly added an additional 5,000.00. The total cost was 13,000.00.

    IF the hospital and provider were all contracted/in-network, the out of pocket cost of care ranges about 3,000.00 to 5,000.00 depending on the plan deductible.

    See the example below:
    Deductible - this amount is due before insurance pays anything to anyone, whether contracted or non-contracted

    Then, Coinsurance - this percent is shared between patient and insurance after the deductible has been met

    Hospital:
    Total amount 13,000.00 contracted rate 7,000.00
    Deductible 3,000.00
    Coinsurance 30% of 7,000.00 - 2,100.00
    Total Amount due to Hospital 5,100.00

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    27. What is a W9 used for?
    When you are a new provider billing insurance for the first time OR if your previous information with insurance has changed, a W9 is required to be provided to each payer so your practice information can be added to system for claim(s) processing.

    https://www.favoredmedicalbilling.com/ProviderUpdate.html

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    28. Is It Worth Submitting A Claim?
    If the provider is NOT contracted with your insurance, there is no reimbursement schedule (allowed amount) to follow which means we have no idea how much the claim will process for.

    Claims are processed as follows:
    Claim sent in at what we think the service is worth = billed amount.
    Your insurance decides what they think the service is worth = allowed amount.
    When the provider is contracted, we know what the allowed amount is and can do the necessary calculations to determine how the claim will process.
    When the provider is NOT contracted, we do not have an allowed amount for the calculation.

    Calculation:
    Allowed amount – patient deductible – coinsurance (% of the allowed amount) = payment.
    IF the deductible is higher than the allowed amount, $0.00 will be paid out and it will all apply to the deductible.
    Issue with non-contracted providers, we do not know what the allowed amount is, the allowed amount may be high enough for a payout, but we would not know until the claim is processed.

    Is it worth submitting a claim?
    Without submitting a claim, the amount paid to your provider cannot be applied to your deductible, and maybe all the stars will align so a payment can be released.

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    29. Understanding the Upfront Cost Collection Process
    Contract Fee
    The contract fee is the set amount enforced by your insurance plan as the allowed amount (what your insurance feels the service is worth) when the provider is in network or contracted with that specific insurance plan. **There are NO contract fees for out of network or non-contracted providers

    Deductible
    This is a flat amounts determined by your insurance plan that the patient is responsible for prior to the insurance plan making any payments on the patient behalf

    Coinsurance
    The Coinsurance is a shared percentage between the patient and the insurance plan

    Out of pocket
    The out of pocket is a flat max amount that the patient is responsible for out of their own pocket ... the out of pocket works in a number of ways
    1. The deductible and or coinsurance amount that is paid by the patient helps meet the out of pocket amount
    2. The plan has neither a deductible and/or coinsurance so the out of pocket is what is collected

    Helpful Hints in-network
    If the contract fee is less than the deductible, then the contract fee is collected,
  • In the event the provider and facility is contracted
  • IF the deductible is met by the provider collection the facility deductible is NOT collected
  • IF after the provider fee deductible is collected but is not met then you collect the facility fee schedule amount up to the amount of the deductible

  • Coinsurance of the contracted fee schedule is collected in addition to the deductible amount(when there is a deductible amount)

    The out of pocket is ONLY collected up to the contracted amount when there is no deductible to collect

    Helpful Hints for out of network
    Since there is no contract fee schedule for out of network providers, some providers will use their personal cost for services to collect the deductible and or coinsurance
    In most cases in terms of reimbursement the insurance plan will use:
    Medicare rates approx.. $2,300.00 (Physician Fee Schedule)

    OR your insurance usual and customary (http://www.favoredmedicalbilling.com/patientfaqs.html#seventeen)

    Verifications are an estimate of cost and not a guarantee of payment.

    Use the link below to review how insurance process claims
    http://www.favoredmedicalbilling.com/patientfaqs.html#five

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    30. Claim Filing Limits
    A claim can be submitted to your insurance immediately AFTER the care is provided.
    In maternity cases, it is best to wait until the baby is delivered before filling a claim.
    IF you transferred from one provider to the other, you can bill services for the 1st provider as soon as you begin care with the 2nd provider.

    Claims filling limits below: You have up until the below time frame from the date of care (For maternity, infant date of birth) to submit your claim to insurance.

    365 days from the date of care
    Aetna
    Blue Cross Plans
    Humana
    United Health Care

    180 days from the date of care
    Cigna

    120 days from the date of care
    Health Net

    90 days from the date of care
    Medicaid Plans

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    31. Which Superbill to Use
    Obstetrics/Gynecology Full – this superbill covers all the below sub options but should only be used if you are submitting all your care at once at the completion of maternity care.

    Confirmation of Pregnancy / Initial Visit - to confirm pregnancy , first initial visit after meet and greet

    Evaluation & Mgmt / Office Visit / Sick Visit - regular office visits

    Family Planning – all family planning and IUD related

    Labor & Delivery – labor and delivery

    Lactation & PP Care / Newborn Follow-up – post partum care for mom and baby

    Ultrasound – ultrasounds

    Well Woman Exam - adult and child well exams

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    32. How to collect when you are INN
    How to Collect the INN Deductible
    IF the deductible is MORE than the fee schedule amount, you collect the full fee schedule amount.
    IF the deductible is LESS than the fee schedule amount, you collect the deductible amount.

    How to Collect the INN coinsurance
    Whatever the percent amount is, you collect that percent of the fee schedule
    Example: Coinsurance 10%, Fee Schedule $100.00. Collect $10.00

    How and When to Collect the INN Out of Pocket
    IF the fee schedule is higher than the OOP and the policy does not have a deductible or coinsurance, collect the full fee schedule amount.
    ONLY collect from the OOP when there is NOT a deductible or coinsurance to collect from.

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    33. How are refund request handled?
    We contact the requestor.
    We ask for a detailed reason for the request.
    We request 60 business days to investigate the refund request on our end.
    We research to see if the request is valid or not.
    When they are valid, we request that the funds are recouped.
    When they are not valid, we have the request appealed and re-researched by the requestor.

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    34. Usual & Customary Medicare Rates
    For out of network providers, there is no fee schedule, so most insurance companies will state services are covered at usual and customary rates which are Medicare rates.

    Description of Usual & Customary
    https://en.wikipedia.org/wiki/Usual,_customary_and_reasonable

    https://www.healthcare.gov/glossary/UCR-usual-customary-and-reasonable/

    You can view the Medicare fee schedule to estimate your U & C.
  • Click the link: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx
  • Click "Start Search" next to the computer icon
  • "Accept" the disclaimer at the bottom of the page
  • Leave all the default selections
  • HCPC CODE
    • 99204 new patient office visit
    • 59426 prenatal care
    • 59400 prenatal care/ delivery/ postpartum care
  • Modifier choose "all modifiers"
  • Submit

  • The page will load:
    First row, 4th column (non-facility price). This is the U & C to use as the insurance allowed amount.

    This is just an estimated process. Since the provider is NOT contracted, there is no guaranteed amount of the U & C or allowed amount.

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    35. Billable Facility Services
  • 1. Each day of "laboring" (mom)
  • 2. The actual delivery date of baby (mom and baby)
  • 3. The date after delivery (mom and baby)
  • 4. NST performed (mom)
  • 5. Ultrasounds performed (mom) NOT Doppler
  • 6. Pap's (mom) for WWE, vagina problem visit (mom)
  • 7. IUD insertions & Removals (mom)
  • 8. IV treatments & Infusions (mom)
  • 9. Hearing Testing (baby)
  • 10. Most Outpatient services (mom) contact Kashuna to confirm
    • a. Tongue Tie (infant)
    • b. Gynecological Service (colpo. Etc.)
    • c. Acupuncture
    • d. Physical Therapy
    • e. Skin Tag Removal
    • f. Diabetes and some other classes (for classes, please submit a description of what is taught/discussed)
    • g. Cyst Removal
    This list will subject to change with new opportunities to bill Back To Top

    36. Report Discrepancy
    Although it is our goal to be as "live" as possible, it is not always possible. Because of this, reports provided can be "different" than what you, the provider, track.

    1. Payments - FMBS is notified of payments received via the provider uploading the EOB, or when working the aging. Based on the time you, the provider, receive payment and FMBS is informed of the payment received, the time can be very different, as provider aging are worked every 6 weeks. To assist in providing the most accurate accounting, IF you receive a payment with no EOB, please know that FMBS has no idea that payment has been, and will not find out until your aging is worked. Please use the link below to notify us so we can assist in obtaining that information.

    Request Missing EOB/Check

    Claims List - Superbills submitted to FMBS are submitted to insurance within 72 hours of receipt. Due to end of the month preparation and closing, superbills received between the 26th and 3rd of the month are held until the month is closed to provide the most accurate accounting. Back To Top

    37. Bill Charge Amounts
    To calculate billed charge amounts, I use Medicare rates times 400%

    Provider
    Mother Global Maternity
    59400 - $8,700.00
    59426 & 59425 - $4,000.00
    ** the above are base rate charges and does NOT include med, additional time, etc…

    Infant initial care
    99460/99464 - $860.00
    ** the above are base rate charges and does NOT include med, additional time, etc…

    Facility
    Mother Facility - $9,800.00
    Infant Facility - $9,400.00
    Education & Hearing - $1,000.00
    IUD & other Outpt - $9,600.00
    Ultrasounds - 3000.00
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    38. HEDIS Request
    View Hedis Request FAQs



    FMBS Billing
    Seminar Registration
    CONTACT FMBS
    Phone: 623-322-0730
    Fax: 1-623-374-4592
    (the 1 is required in front)
    Email:
    info@favoredmedicalbilling.com

    We look forward to hearing from you.
    Mrs. Kashuna Hopkins
    OFFICE HOURS
    Office Open:
    Monday – Thursday,
    9AM to 2PM Arizona Time

    Office Closed:
    Fridays

    Holidays Closed:
    Martin Luther King, Jr. Day
    President's Day
    Good Friday
    Memorial Day
    Independence Day*
    Labor Day
    Thanksgiving Weekend (Thu/Fri)
    Christmas Break (12/24 - 1/1)*

    *If the holiday falls on a Saturday, the closure is observed on the Friday preceeding. If the holiday falls on a Sunday, the closure is observed on the following Monday.