Need help filling out claim form
Hi all! I had a tummy tuck in October after a 90 pound weight loss. My dr. was adamant that it was purely cosmetic but agreed to send in a pre authorization to insurance. I received the denial a few days after I had the surgery (I paid out of pocket as I was pretty sure I would have to anyway). I decided to appeal the denial with insurance and finally in January I was approved for the panniculectomy portion of the surgery. Unfortunately in that time my dr. left the practice he was in and opened his own practice. If insurance wouldn't have taken almost 3 months to review my appeal my situation wouldn't be what it is today and that's why I need help.
The old practice will not file a claim on my behalf because the dr. is no longer there. They DID provide me with some records and a copy of the bill. The new practice is not set up for insurance so the dr. won't help me either. :( I'm at my wits end and am now attempting to file the claim myself. But, having a problem filling out the claim form (a typical Form 1500, it's red and white). Most of the form is self explanatory but I have no idea what to put in for a diagnosis or nature of illness code. I thought I would google weight loss but the only code I can find for that is unexplained weight loss, and that doesn't fit. I'm afraid to leave it blank. Also, there was no referring provider so not sure if I can leave that blank or not. And, date of current illness? Would I put the same date as the actual surgery? There is another spot for all that so I think not but there is no "current illness".
Is there anyone out there that has any insurance or medical office knowledge that could help me? I would really appreciate it!!!!
Ask the practice to print you a HCFA 1500 with your Dr's charge on it and go to the hospital where the procedure was done and ask for a billing statement or a UB40 printout. That is something they are required to do if you request it. They also have to provide you with the diagnosis code as well as the ICD 10 codes and CPT codes so you can submit payment. Without the proper codes (of what the procedure(s) were) the insurance cannot adjudicate the claim. Additionally, you will need his TIN/NPI # that identifies him as a credentialed Dr. If the surgeon's office balks at assisting you, tell them you will report them to the insurance commissioner in your state.
Once you get the items above, submit those two items to your insurance carrier with a copy of your approval letter, a copy of your payment (canceled check or receipt for payment) to the providers for reimbursement. Write a letter that you paid for the procedure out of your own pocket, so that all payments should be made directly to you and not the providers.
A three-month review process is common in the insurance industry unless it is an emergent case, but you have between 90-180 days to get the claim filed depending on your carriers guidelines.
Did he give you a copy of your Operative Report? If so, the insurance carrier could pull the data from that to reimburse you and you won't need the CPT/ICD 10 or Diagnosis codes. Also, if the hospital gives you a print out, those should be on it, as your surgeon was required to dictate a History and Physical as well as the Op Report and generally that info is included in the report.
Your referring physician code will be left blank - that is only needed if there was one.
Leave the date of current illness blank
Just fill in the DOS (Dates of service) with the date you had surgery
