CareSync Medical Billing leverages Electronic Claim Submission (ECS) to revolutionize the healthcare industry. By enabling the direct digital transmission of claims, ECS eliminates the need for paper and streamlines the adjudication process. This innovative approach ensures faster claim processing, reduces errors through electronic data entry, streamlines the billing process, and enhances security, making it the standard for claim submission at Caresync Medical Billing and across the healthcare industry.

Introduction:
This Standard Operating Procedure (SOP) outlines the step-by-step process for submitting electronic claims at CareSync Medical Billing. Adherence to this procedure ensures timely and accurate claim submissions, leading to optimal reimbursement rates.

1. Data Verification and Preparation:
– Patient Demographics: Ensure accuracy of patient information, including name, date of birth, Social Security number, address, and contact details.
– Insurance Information: Verify the accuracy of insurance carrier, policy number, group number, and effective dates.
– Provider Information: Confirm the provider’s National Provider Identifier (NPI) and other necessary details.
– Diagnosis Codes: Utilize the correct International Classification of Diseases (ICD) codes to accurately represent the patient’s diagnosis.
– Procedure Codes: Employ the appropriate Current Procedural Terminology (CPT) codes to describe the services rendered.
– Modifiers: Apply any necessary modifiers to clarify the circumstances of the service.

2. Claim Creation and Entry:
– Claim Form: Use the appropriate electronic claim form, such as the 837D or 837P, depending on the payer’s requirements.
– Data Entry: Accurately enter all required fields in the claim form, ensuring consistency with the verified information.
– Coding: Apply the correct ICD and CPT codes as determined in the previous step.
– Modifiers: Include any necessary modifiers.
– Attachments: Attach any supporting documentation, such as medical records or authorizations, as required.

3. Claim Review and Editing:
– Internal Review: Conduct a thorough review of the claim to identify and correct any errors or inconsistencies.
– Scrubbing: Use claim scrubbing software to verify the accuracy of codes, payer information, and other claim elements.
– Edit Checks: Implement edit checks to ensure compliance with payer-specific rules and regulations.

4. Electronic Submission:
– Payer Portal: Access the payer’s electronic portal or clearinghouse.
– File Transmission: Submit the claim electronically using the appropriate file format and transmission method.
– Acknowledgment: Receive an acknowledgment from the payer confirming receipt of the claim.

5. Claim Follow-Up:
– Payment Posting: Monitor the payer’s portal or clearinghouse for payment or denial notices.
– Denial Appeals: If a claim is denied, review the reason for denial and determine if an appeal is necessary.
– Resubmissions: Resubmit claims with corrected information or additional documentation as required.
– Timely Filing: Ensure compliance with payer-specific timely filing requirements.

6. Record Keeping:
– Claim Documentation: Maintain a copy of each submitted claim, along with any supporting documentation.
– Payment History: Record payment or denial information for each claim.
– Appeal Tracking: Track the status of any appealed claims.

7. Compliance and Quality Assurance:
– Regular Audits: Conduct periodic audits to assess the accuracy and completeness of claim submissions.
– Training and Education: Provide ongoing training to staff on claim submission procedures and industry updates.
– Compliance Standards: Ensure compliance with all relevant federal and state regulations.

By following this SOP, CareSync Medical Billing can streamline its claim submission process, reduce errors, and improve reimbursement rates. Regular review and updates to the SOP are essential to maintain its effectiveness.