The particular type of insurance covering the expenses involved with treatment of injuries and medical conditions that arise out of jobs is known as workers’ compensation. Differing from other types of medical insurance and having limitations, this type of insurance needs to be handled cautiously.
Fundamentals of Workers’ Compensation Claims
When most of the other health insurance processes have been automated, workers’ compensation claims are still being processes in the manual mode. This is because of the fact that this type of insurance claims necessitates greater supervision and scrutiny for ensuring that the affected claimant has in fact contracted a workplace-related injury and is undergoing injury-based medical treatment. Billing procedure for this type of claim includes the major phases of claim filing, patient treatment, and claim processing.
Major Phases in Workers’ Compensation Claims Process
– Claim Filing: The first step is filing of the claim by the injured employees through their workers’ compensation insurance provider – the employee is given a claim number that acts as the unique ID number; the insurance provider authorizes employee’s treatment and assign the adjuster and reviews the recovery of the employee – CMS-1500 claim form is used for submitting workers’ compensation claims
– Patient Treatment: Upon being authorized by the adjuster for treatment, the employee becomes the patient of the health care provider – services will be billed separately, and not to the employee’s personal medical insurance – a comprehensive plan for treatment is developed
– Claim Processing: After reviewing the charges as per CMS-1500 as well as the relevant progress notes attached, the adjuster confirms that services provided are in line with work-related injury and are authorized according to the treatment plan – unauthorized and unrelated services will not be paid for, but the employee cannot be held liable for the same
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