If you are an out of network provider, you know the importance of properly communicating to your clients to sign over received insurance checks. I suggest you do this on 3 occasions.
- When you realize the patient has BCBS have the initial conversation to prepare them, even create and sign a separate contract
- The last visit before they deliver
- At their PP visits
Please feel free to use the link below for verbiage options
Help your Triwest clients get coverage.. provide a claim form and have then submit the Triwest reimbursement form.
Claims Address: https://tricare.mil/FormsClaims/Forms/ClaimForms/Medical/Addresses
TRICARE Policy Manual 6010.57-M Chapter 11 Section 3.12
Certified Nurse Midwife (CNM) Authority: 32 CFR 199.6(c)(3)(iii)(D)
1.0 ISSUE Certified Nurse Midwife (CNM).
2.1 A CNM may provide covered care independent of physician referral and supervision,
provided the nurse midwife is:
2.1.1 Licensed, when required, by the local licensing agency for the jurisdiction in which the
care is provided; and
2.1.2 Certified by the American Midwifery Certification Board (AMCB). To receive certification, a
candidate must be a Registered Nurse (RN) who has completed successfully an educational
program approved by the AMCB, and passed the AMCB National Certification Examination.
2.2 The services of a RN who is not a CNM may be authorized only when the patient has been
referred for care by a licensed physician and a licensed physician provides continuing supervision
of the course of care.
A lay midwife who is neither a CNM nor a RN is not an authorized provider, regardless of
whether the services rendered may otherwise be covered.
It has certainly been tough switching all my providers from Triwest UHC to HN. I found out today while checking on claims (that I was required to wait until 5/1/18 to follow up on), that Triwest HN will not credential nor process claims for Midwives that are not CNMs. Please see the manual I was directed to.
Below are a few audio webinars on Out of Network Billing, Patient Collections, Billed Charges, Telemedicine and some recently shared pointers. Audio credit to Audio Educator shared pointers credit to Larsen Billing Company
- The Balance Billing Requirement – Why Out-of-Network Providers Must Balance Bill Their Patients
- Telemedicine 2017: Coding, Billing and Compliance Update
- Reconciling Cigna v. Humble with Aetna v. Humble and Their Impact on the Out-of-Network Provider
4. Larsen Billing – You, the provider, are responsible for coding. Billing services give advice and make suggestions on coding all the time, but if you cannot find evidence in the code books for the advice as it pertains to your services, you should not allow them to bill on your behalf. So even if your billing service picks your codes, you have ultimate responsibility for all of them.
- States vary, but there is no overall statute of limitations on take backs, audits, or insurance fraud. That means that even if a code pays for ten years, it could be audited or investigated by the insurance company or local authorities, and you will be held liable to pay back, usually with interest, all funds that were improperly coded. A good billing service stands by their billing and coding and will help you gather the needed information in the case of an audit.
United Health Care has started a recent trend… just wait, it is not a good trend. UHC has denied claims stating insufficient medical records even though records has NOT been officially requested. Please update your billers so these services are NOT prematurely written off.
Submit the claims, records, and denial of insufficient records for reprocessing.