How to File a Claim

One of the most critical functions in a provider’s office is insurance claims submission. ActivHealthCare understands the importance of this task and is here to help you manage your outstanding insurance receivables. By utilizing AHC’s insurance billing service, we will work on your behalf to resolve all outstanding insurance claims.

For specific plans it is necessary to submit the claims for your patients’ services on paper and through U.S. mail. To facilitate those claims, send them directly to the address on the back of the patient’s insurance identification card. If you are not sure about where to submit the claim, call the number for the company on the insurance card. They will give you the most accurate information.

The steps for claims processing are as follows:

Step 1	Verify patient’s insurance coverage through insurance payor. Be sure to verify that you are listed in the PPO network, if applicable.
Step 2	Thoroughly complete the Health Insurance Claim Form. This is often referred to as a HCFA1500 or CMS-1500. Be sure to pay attention to the requested information. The following boxes are often completed incorrectly on the CMS-1500:
	1a.	Insured’s ID number
	4.	Insured’s name
	8.	Full-time student (if appropriate & child is 18 or over)
	9a-d.	Other insurance information (if applicable)
	10a-c.	Patient’s condition related to: (extremely important)
	11.	Insured’s policy group or FECA # (see ID card)
	11a.	Insured’s date of birth & sex
	11b.	Employer name (see ID card)
	11c.	Insurance plan name (list PPO network name) (Obtain from the ID card)
	14.	Date of current illness or injury
	31.	Provider’s name (this should be a signature)
	32.	Name & address of facility (put office address here)
	33.	Physician’s suppliers billing name (we will replace your information in this field with the AHC information)
	The list above in not comprehensive, but these are the fields that are often left blank or completed incorrectly. Please be sure to become familiar with the form and the process your office follows for completing it. If the form is not completed it will either slow down the claims process or result in the claim being denied by the insurance payor.
Step 3	The upper right hand corner (above box 1a.) of the CMS-1500 form has a blank space. Many providers use this place to print the name and address of the insurance payor. If the claim is sent to AHC for processing, some providers will place our name and address in this field. Although that helps you know to send the claim to AHC, it does not help AHC know where to send the claim for payment.
	In order to identify the name and the address of the ultimate insurance payor, we request that you complete this field in the following format:
		AHCØ1 Insurance Payor’s Name
		Insurance Payor’s Street Address or P.O. Box
		Insurance Payor’s City, State & Zip Code
	Obtain the insurance payor’s information from the insurance identification card. By placing the AHCØ1 prefix in FRONT of the insurance payor’s name, you will know to send the claim to the AHC office. This format will expedite the processing of your claims by providing AHC with the Payor’s address on the CMS-1500. View Example 2.
	Remember, we get the insurance payor’s information from you. By working together, we can recover every benefit dollar possible.
	If we do not know the billing address of the insurance claims payor or the name of the PPO network (box 11c), we will have to request a copy of the insurance ID card from you.
Step 4	Send the claim to the AHC office. AHC processes some claims in house, but most claims must be sent to a third party for processing. If the claim form is completed properly, AHC will send your claim to the appropriate insurance payor within 24 hours after receiving the claim. We will also enter or log the claim into our centralized billing system.
Step 5	In most cases the insurance claims payor will process the claim and send AHC an explanation of benefits within 30 days. We will promptly process the claim through our system and issue a bulk pay remittance to you summarizing all claims processed for your office during the week.
Step 6	In some cases, the carrier may not process a claim promptly. If the carrier needs additional information, they may respond to you directly or to AHC. If they request the information from AHC, we will relay that request to you.
	If the carrier fails to respond on a claim, AHC will resubmit the claim to the carrier. We will continue to follow up on the claim until it is resolved.