PATIENT DEMOGRAPHICS – AN OVERVIEW - 3

V. Insurance Information
This segment of face sheet contains all active insurance information of the patient. This segment includes primary, secondary, and/or tertiary insurance information. This segment is the most important field in patient demographic sheet. Information found in this field should always be the updated & correct one. If not, we would be submitting claims to incorrect insurance. Entry persons should always match this information with copy of insurance id cards. (if provided). This will reduce the risk of entering incorrect insurance information. Following information are found in this segment

1. Insurance Code/Name
2. Effective Date
3. Subscribers Name
4. Relationship Code
5. Pre-Certification/Pre-Authorization
6. Referral Number
7. Primary Insurance Group #
8. Primary Insurance Policy #
9. Date of Injury/Accident
10. Claim Number

1. Insurance Code/Name: This field is used to enter the insurance code or name of the coverage that the patient has. The insurance code is assigned by the Billing office for its internal purpose to reduce the PD entry time. Each Insurance company’s name, billing address, contact person, etc… are assigned a unique code. The entry person should be very careful while selecting the insurance code and should always verify the billing address with the given card copy or with the billing address given on the encounter form.
The Primary insurance name is printed in the 11c field and the Secondary insurance name is printed in the 9d field of the CMS-1500 claim form.

Example:
Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …

2. Effective Date: This field contains the effective date of coverage. This date should not be after the Date of Service. The date format is MMDDYYYY. This date is used for the internal purpose of the Billing office and Hospitals. This does not form part of the HCFA-1500 claim form.

Example:
Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …

3. Subscribers Name: This field contains the Subscribers name of the insurance policy. If the patient is a dependant who is covered under someone else’s policy then the name of the person who pays the premium is entered in this field. If patient is the subscriber then we need to enter the patient name itself. The name is entered in the Last Name, First Name MI format.
The Primary insurance subscribers name is printed in the 4th field and the Secondary insurance subscribers name is printed in the 9th field of the CMS-1500 claim form.

Example:
Subscriber: John Q. Public; Public, John Q …

4. Relationship Code: This field contains the relationship of the subscriber to the patient. The code is usually 1 – Self, 2 – Spouse, 3 – Parent, 4 – others etc…
This field does not form part of the CMS-1500 claim form.

5. Policy ID: This field contains the Policy number given by the insurance company to the subscriber and the dependants of the policy. This does not have any standard format across the insurance company but each insurance company has a unique format such as for Medicare the policy number is given as SSN + Alpha or Alphanumeric. The policy ID should be entered as given in the scanned card copy or as mentioned on the Encounter form.
The Primary insurance ID is printed in the 11th field and the Secondary insurance ID is printed in the 9a field of the CMS-1500 claim form.

Example:
Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …

6. Group ID: This field contains the Group ID as given by the insurance company for the policy. Not all the insurance companies have the Group ID hence if not given then this field can be left blank.
The Group ID is printed along with the Policy ID on the CMS-1500 claim form.

7. Pre-Auth. / Pre-Cert. Number: Review of "need" for inpatient care or other care before admission. This refers to a decision made by the payer, Managed Care Organization, or insurance company prior to admission. The payer determines whether or not the payer will pay for the service. Most managed care plans require pre-cert. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered. An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors, and maximums. Under some programs, for instance, pre-determination by the third party is required when covered charges are expected to exceed a certain amount. This number should be attached with the respective claim; otherwise the claim will be rejected. There is no standard format for Auth and Pre-Cert. number across all the insurance companies. Each insurance company has its own unique format of Auth and Pre-Cert. numbers.
This field is printed in the 23rd field of the CMS-1500 claim form.

8. Referral Number: A Referral number is provided by a PCP (Primary Care Physician) when he refers a patient to a specialist. Without the Referral number a patient cannot get a specialist’s service if he has a HMO plan.
This number is printed on the CMS-1500 claim form or entered in the attached documents as per the Insurance company requirements.

9. Date of Injury/Accident: This field is used to enter the Date of Injury/Accident when the claim is filed to Work Comp/Auto Accident insurance. This date is useful for the insurance companies to verify if the coverage was active or not. This date is mentioned in the documents attached while filing the claim.

10. Claim Number: This field is used to enter the Claim number for a particular claim given by the Work Comp/Auto Accident insurance company. Failing to mention this number on the claim form will result in the rejection of the claim.
This is mentioned in the attached documents while submitting the claim.