Claim forms must be completed in their entirety. The accuracy in which the claim form is completed directly effects the efficiency in which the claim is processed for payment. Line items left blank on the HCFA can result in the claim being returned to the provider, therefore, delaying payment.
**A written referral or authorization number is not necessary when referring to another participating physician in the 4MOST Health Network. The benefits, however, may differ if not referred to a participating physician or hospital. Please refer to our Provider Directory or our website;
Important Definitions
Co-Insurance:
**Co-insurance is a provision of each benefit plan by which the participant shares in the cost of various covered services on a percentage or flat rate basis. These too will vary by benefit plan. The benefit plan will pay their percentage of the maximum allowable or flat rate amount set forth in the negotiated fee schedule, the participant will be responsible for the remaining amount up to the stated maximum allowable, (ie: benefit plan pays 80%, the participant pays 20%).
· Because appropriate discounts are not applied to the claim until it is adjudicated, do not collect the co-insurance amount until the final explanation of benefits (EOB) has been received and reviewed for the correct remittance amount. No amounts, other than co-pays and/or deductibles should be collected in advance.
Co-payments:
**Co-payments are generally fixed amounts rather than a percentage and are due at the time the services are rendered. Co-payment amounts are most often found on the participant's ID card. These amounts will vary depending on the individual plan. It is recommended that a copy of each member's card be made at the time of each visit.
Deductibles:
**The amount of covered charges that the Insured Person must pay each calendar year before the policy pays major benefits.
Allowed Amount:
** The allowed amount is the contracted amount allowed after the PPO discount is subtracted from the total billed amount. The difference between the billed amount and the allowed amount must be adjusted off.
Claims Repricing:
**Claims are sent to 4MOST to apply applicable PPO discounts for in-network providers. Claims are then forwarded to the TPA or Insurance Company for processing of payment. There is a one to three day turn around time on the claims; from the time 4MOST receives the claims to the time 4MOST mails the claims to the appropriate payor for adjudication.
Third Party Administrator (TPA):
**An organization hired by certain employers to facilitate benefit plan determinations and processing of benefit plan claims. TPA's do not assume the financial risk or liability of making such benefit plan payments only the remittance of benefits upon final approval of the employer. TPA's & employers partner with managed care organizations, like PPO's, to obtain provider discounts and to assist in controlling health care quality and total plan cost.
Insurance Carrier:
**An organization that sells insurance contracts to certain individuals and employers, whereby the insurance carrier assumes the full financial risk and liability of making benefit plan determinations, processing of such benefit plan claims and the remittance of benefit plan payments. The individual and employer purchasing such insurance contracts have no approval or denial abilities of actual benefit payments or the decision affecting such payments. Insurance carriers also partner with managed care organizations, like PPO's, to obtain provider discounts and to assist in controlling health care quality and total plan cost. Insurance companies cal also act as claims administrators only, when they act in this fashion they are referred to as ASO accounts or Administrative Services only.
Explanation of Benefits (EOB):
**An explanation of benefits (EOB) will be issued to the physician each time services are submitted to a contracted claims administrator and benefit plan and reimbursements are assigned to the physician. This statement will identify the participant, date of service, procedure(s) performed, amount charged, allowable amount, percentage of coverage, applicable co-payments/co-insurance and deductibles applied, and the patients financial responsibility. Please Note: you may "not" collect the difference between your charged amount and the maximum allowable from the participant. This is the contracted discount.
Coordination of Benefits:
**When a participant has two benefit plans covering services provided, benefits are coordinated to potentially pay 100% of covered charges. You or your staff should contact the claims administrator directly in order to verify the rules used to determine the order of benefit payment. Please note: if the 4MOST contracted payor is not the primary payor, then reimbursement to participating providers from 4MOST contracted payor shall not exceed the amount allowed by the 4MOST Integrated Health Network fee schedule.
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