How Can I File A Claim?
There are a few different options for filing a healthcare claim. Some options might be limited due to the payer’s ability to process claims through a portal. They may specifically request to have the share sent via mail; regardless, there are four recommended methods for filing a claim with a payer. Follow along below as each of the four methods is reviewed to identify which one(s) might be the best option for you and your ABA agency.
Option 1: Mail-In Claims – Form 1500
- Certified/Tracking: Whenever mailing supporting documents or claims, send them through certified mail with a tracking number.
- Supporting Documents: ·Whenever submitting a claim through the mail, ensure that you have included all the supporting documents. If you are resubmitting a claim, make sure you include any documents from the initial claim, such as the EOB. (Stall, Brinkman & Padula, 2021)
Mailing claims is not ideal for a few reasons. It takes longer to be received, the provider will not know when they received it, and it could take days to get it back, make corrections and then resubmit it again. The need to mail a claim could be because the payer does not accept claims through the clearinghouse, or the payer may not have a portal (Stall, Brinkman & Padula, 2021). When the time comes when a claim needs to be mailed in, remember to review the considerations discussed above.
Option 2: Electronically Online – Form 837p or 837i
- Online Portal: Most payers will have an online portal where the provider can create an account. The ABA provider would then fill out the corresponding form and upload it directly through the online portal.
- Be Vigilant: Pay close attention to the accepted forms through the online portals. Some ABA providers will fill out a 1500 and upload it, and the payer will accept it, while others may not. Note, “837p = HIPAA secure claims format for professional claims; 837i = HIPAA secure claims format for institutional claims.” (Stall 2021).
Be prepared for variations in how the payers are requesting claims submissions. Have all necessary data, reports, and documents on hand and ready to submit with the claim. Some payer’s portals have the claim forms online that can be filled out electronically line by line, while others allow you to upload the document. Electronic submission through the payer portal is more efficient than mail-in; however, the responses from the payer are not immediate. The provider may not know the claim was denied until they receive the EOB (Stall, Brinkman & Padula, 2021).
Option 3: PMS/EHR/Clearinghouse
- Providers can create and submit claims through the PMS or EHR systems connected to a clearinghouse.
- The clearinghouse completes editing first (i.e., before the claim goes to the payer) to ensure the claim is clean when the payer receives it.
- The ABA providers can set up PMS/EHR system with the Clearinghouse feature as an additional denial avoidance strategy. Still, fees would apply for claim scrubbing and submissions through the clearinghouse.
- Claims can be sent back for edits from the clearinghouse for claims’ payments and denial information if the claim is denied after the payer processes it. (Stall, Brinkman & Padula, 2021)
The next option is submitting claims through PMS (Practice Management Solutions) or EHR (Electronic Health Record). Once the claim is submitted through one of these systems, it goes to the clearinghouse first for edits. Claims that go through these systems are considered best practice and most efficient. The clearinghouse and ABA provider can send responses back and forth to discuss what the ABA provider can correct before submitting the claim to the payor (Stall, Brinkman & Padula, 2021).
Option 4: Third-Party Vendor
- Ensure that the third-party vendor is up to date on HIPAA regulations and guidelines to protect your practice/business.
- ABA providers should execute BAA (Business Associate Agreements)
- Terms (statement of work) should be clearly defined – roles/responsibilities of third-party vendor included in a signed agreement
- KPI driven results – check in weekly or monthly to discuss RCM KPIs defined
- Automation capabilities for billing should be provided by third-party vendors (i.e., claim submission EDI, ERA (electronic remittance), and workflow automation
Partnering with a third-party vendor specializing in billing management and revenue cycle processing specifically for ABA agencies allows the practice to focus on providing and delivering care. There are other options available for ABA providers who are ready to move on from the aversive feeling of ongoing administrative work, denied claims, or missed opportunities for maximum reimbursement (Stall, Brinkman & Padula, 2021).
Looking for a step-to-step guide on submitting accurate and timely claims? Download our Claim Submission Cheat Sheet – a one-page interactive/printable pdf to assist you in managing your claims processing.
Therapy Brands provides specialty software explicitly designed for ABA organizations, offering dedicated billing experts and industry-leading PMS and RCM software. Therapy Brands is knowledgeable on the revenue cycle and has helped businesses maintain, and even surpass, the industry standard of 90-95% clean-claim submissions. Our practice management solutions offer many advantageous PMS and RCM options for ABA practices, both small and large scale.
Stall, D., Brinkman, M., & Padula, N. (2021). Billing 101: Claims Processing – Ensuring Efficient Management of Your Revenue Cycle. Presentation, webinar.