Billing Insurance (Aetna, BlueCross, etc.) – How to Bill Insurance as a Provider

Here’s a comprehensive guide on billing insurance for some of the major insurance companies, including Aetna, BlueCross BlueShield, Cigna, UnitedHealthcare, Oxford, and Oscar. This guide will cover CPT codes, ICD-10 codes, telehealth codes, billing limitations, definitions of preventive services, and best practices for obtaining reimbursements.

How to Bill Insurance as a Provider for Major Insurance Companies

Aetna

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Diagnostic tests: 80050-87999

ICD-10 Codes They Typically Accept:

  • Diabetes: E10-E14
  • Hypertension: I10-I15
  • Respiratory infections: J00-J06
  • Preventive health exams: Z00.00-Z00.8

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive medicine: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90791, 90792, 90832-90838 (with modifier 95 or GT)

Typical Billing Limitations:

  • Preauthorization for certain services and procedures.
  • Limits on the number of visits for therapy or chiropractic care.
  • Exclusions for experimental or investigational treatments.

Preventive Services Definition:

  • Aetna defines preventive services as routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Best Practices for Getting Paid:

  • Verify patient eligibility and benefits before services are rendered.
  • Obtain necessary preauthorizations.
  • Submit clean claims with correct coding and documentation.
  • Follow up on unpaid claims regularly.

BlueCross BlueShield (BCBS)

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Laboratory tests: 80048-89398

ICD-10 Codes They Typically Accept:

  • Asthma: J45
  • Obesity: E66
  • Mental health: F20-F48
  • Routine health checks: Z00-Z13

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive medicine: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90834, 90837 (with modifier 95 or GT)

Typical Billing Limitations:

  • Preauthorization for high-cost imaging and certain specialty treatments.
  • Annual limits on physical, speech, and occupational therapy.
  • Exclusions for non-FDA approved treatments.

Preventive Services Definition:

  • BCBS considers preventive services to be medical services that are intended to prevent illnesses or detect issues before symptoms develop, such as vaccinations, screenings, and wellness visits.

Best Practices for Getting Paid:

  • Ensure accurate patient information and insurance details.
  • Submit claims electronically for faster processing.
  • Use the correct modifiers and codes.
  • Keep up with policy changes and updates.

Cigna

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Radiology: 70010-79999

ICD-10 Codes They Typically Accept:

  • Hypertension: I10
  • Hyperlipidemia: E78
  • Depression: F32
  • Health check-ups: Z00.00-Z00.8

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive services: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90834, 90837 (with modifier 95 or GT)

Typical Billing Limitations:

  • Authorization for specialty services and surgeries.
  • Annual limits on alternative therapies.
  • Certain durable medical equipment requires preauthorization.

Preventive Services Definition:

  • Cigna defines preventive services as services that focus on disease prevention and health maintenance, including routine check-ups, screenings, and immunizations.

Best Practices for Getting Paid:

  • Confirm patient coverage and preauthorization requirements.
  • Ensure proper use of ICD-10 and CPT codes.
  • Submit claims promptly and follow up on denials.
  • Maintain thorough and accurate patient records.

UnitedHealthcare

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Physical therapy: 97001-97799

ICD-10 Codes They Typically Accept:

  • Diabetes: E10-E14
  • Anxiety: F41
  • Cardiovascular diseases: I20-I25
  • Routine health exams: Z00-Z13

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive medicine: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90834, 90837 (with modifier 95 or GT)

Typical Billing Limitations:

  • Preauthorization required for many elective procedures.
  • Limits on the number of visits for certain therapies.
  • Non-covered services include cosmetic procedures and certain experimental treatments.

Preventive Services Definition:

  • UnitedHealthcare defines preventive services as those aimed at preventing illness and promoting health, such as screenings, immunizations, and counseling.

Best Practices for Getting Paid:

  • Use their online portal to verify benefits and obtain preauthorizations.
  • Submit claims electronically and ensure all documentation is complete.
  • Stay updated on coding guidelines and payer policies.
  • Follow up on unpaid claims and resubmit if necessary.

Oxford

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Diagnostic services: 70010-79999

ICD-10 Codes They Typically Accept:

  • Obesity: E66
  • Hypertension: I10
  • Depression: F32
  • Health examinations: Z00-Z13

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive medicine: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90834, 90837 (with modifier 95 or GT)

Typical Billing Limitations:

  • Prior authorization for high-cost services.
  • Limits on alternative therapies and some outpatient services.
  • Non-covered services may include experimental treatments.

Preventive Services Definition:

  • Oxford considers preventive services as those that prevent or detect illness early, such as screenings, immunizations, and routine physicals.

Best Practices for Getting Paid:

  • Verify patient eligibility and preauthorization requirements.
  • Ensure accurate coding and timely claim submission.
  • Use electronic billing for efficiency.
  • Follow up on denied or unpaid claims.

Oscar

CPT Codes They Typically Accept:

  • Office visits: 99201-99215
  • Preventive care: 99381-99397
  • Immunizations: 90460-90474
  • Mental health services: 90832-90838

ICD-10 Codes They Typically Accept:

  • Hypertension: I10
  • Diabetes: E10-E14
  • Mental health: F20-F48
  • Routine health checks: Z00-Z13

Current Telehealth Codes:

  • Office/outpatient visits: 99201-99215 (with modifier 95 or GT)
  • Preventive services: 99381-99397 (with modifier 95 or GT)
  • Behavioral health: 90834, 90837 (with modifier 95 or GT)

Typical Billing Limitations:

  • Prior authorization for certain specialty services.
  • Annual limits on therapy visits.
  • Exclusions for certain non-standard treatments.

Preventive Services Definition:

  • Oscar defines preventive services as measures to prevent illness or detect it early, including screenings, immunizations, and annual physical exams.

Best Practices for Getting Paid:

  • Use Oscar’s provider portal to verify benefits and obtain preauthorizations.
  • Submit claims electronically and ensure all required documentation is included.
  • Keep up-to-date with coding guidelines and insurance policies.
  • Regularly follow up on unpaid claims and address denials promptly.

Summary Checklist for Billing Major Insurance Companies

  • CPT Codes: Know the common CPT codes each insurer accepts.
  • ICD-10 Codes: Be familiar with the ICD-10 codes typically used for billing.
  • Telehealth Codes: Use the correct telehealth codes and modifiers.
  • Billing Limitations: Understand each insurer’s limitations and preauthorization requirements.
  • Preventive Services: Know how each insurer defines and covers preventive services.
  • Best Practices: Verify patient eligibility, use electronic billing, ensure accurate coding, obtain preauthorizations, and follow up on claims.

Understanding Superbills, HSAs/FSAs, and Billing Practices

Superbills

Superbills are detailed receipts provided to patients after they receive medical services. They allow patients to submit a claim to their insurance company for reimbursement if the provider does not bill the insurance directly.

Components of a Superbill:

  1. Patient Information: Name, date of birth, and contact details.
  2. Provider Information: Name, address, NPI number, and contact details.
  3. Service Date: Date(s) of service provided.
  4. Description of Services: Detailed list of services provided, including CPT and ICD-10 codes.
  5. Charges: Fees for each service.
  6. Payments: Amount paid by the patient at the time of service.
  7. Provider Signature: Authorized provider’s signature.

Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs)

HSAs and FSAs are tax-advantaged accounts that patients can use to pay for qualified medical expenses.

HSA:

  • Eligibility: Available to individuals with high-deductible health plans (HDHPs).
  • Contributions: Funded by the individual, employer, or both. Contributions are tax-deductible.
  • Rollover: Funds roll over year to year.
  • Qualified Expenses: Includes medical, dental, vision, and prescription costs.

FSA:

  • Eligibility: Offered by employers as part of a benefits package.
  • Contributions: Funded by the employee through payroll deductions. Contributions are pre-tax.
  • Rollover: Funds generally must be used within the plan year, with some plans allowing a small rollover or grace period.
  • Qualified Expenses: Includes medical, dental, vision, and dependent care expenses.

Identifying Billable Services

Services You Can Bill Insurance For:

  1. Office Visits: Routine check-ups, consultations, follow-up visits.
  2. Preventive Care: Vaccinations, screenings, wellness exams.
  3. Diagnostic Tests: Blood tests, X-rays, MRIs, and other diagnostic procedures.
  4. Therapies: Physical therapy, occupational therapy, speech therapy.
  5. Procedures: Minor surgical procedures, biopsies, wound care.
  6. Mental Health Services: Counseling, psychiatric evaluations, therapy sessions.

Services You Can Bill the Patient For:

  1. Non-Covered Services: Cosmetic procedures, elective services not covered by insurance.
  2. Out-of-Network Services: Services provided by out-of-network providers, if the patient’s plan doesn’t cover them.
  3. Deductibles, Co-pays, Co-insurance: Patient responsibility based on their insurance plan.
  4. Missed Appointment Fees: Charges for missed appointments if your practice policy allows.
  5. Supplies and Supplements: Medical supplies, vitamins, and supplements not covered by insurance.

Typical Fees Collected at an Insurance-Based Patient Visit

  1. Co-pay: A fixed amount the patient pays at the time of service.
  2. Deductible: The amount the patient must pay out-of-pocket before the insurance begins to cover expenses.
  3. Co-insurance: A percentage of the cost of services that the patient pays after meeting their deductible.
  4. Balance Billing: The practice of billing the patient for the difference between the provider’s charge and the amount covered by insurance (if allowed by the insurance contract).

Example:

  • Office Visit Fee: $100
  • Co-pay: $20
  • Remaining Balance: $80 (insurance covers $60, patient pays $20 as co-insurance)

Balance Billing

Balance Billing occurs when a provider bills the patient for the difference between what the insurance pays and the provider’s total charge. This practice is often restricted or prohibited by insurance contracts, especially for in-network providers.

Scenarios When Balance Billing May Apply:

  1. Out-of-Network Providers: When a patient sees a provider not covered by their insurance plan.
  2. Non-Covered Services: Services that are not included in the insurance coverage.

Term Balance Billing: Ensuring that billing practices comply with legal and contractual obligations.

Scenarios for Co-pays, Deductibles & Co-insurance

  1. Co-pay:
    • Scenario: Patient visits a primary care physician for a routine check-up. The co-pay is a fixed amount, such as $20, due at the time of the visit.
  2. Deductible:
    • Scenario: Patient undergoes a surgical procedure. The patient must pay a deductible amount (e.g., $1,000) before insurance covers the remaining costs.
  3. Co-insurance:
    • Scenario: After meeting the deductible, the patient receives additional medical services. The insurance covers 80% of the cost, and the patient pays the remaining 20% as co-insurance.

Documentation vs. Referral

Documentation:

  • Comprehensive medical records including patient history, diagnosis, treatment plans, and progress notes.
  • Essential for billing, legal compliance, and continuity of care.

Referral:

  • A formal recommendation from a primary care provider to a specialist.
  • Often required by insurance plans (especially HMOs) for the specialist visit to be covered.

Securing Referrals

  1. Identify Need:
    • Determine if the patient’s condition requires a specialist’s evaluation.
  2. Verify Insurance Requirements:
    • Check if the patient’s insurance plan requires a referral for specialist visits.
  3. Referral Process:
    • Complete and submit the referral form through the insurance provider’s portal or via fax.
    • Provide the patient with referral details, including the specialist’s contact information and appointment instructions.
  4. Follow-Up:
    • Ensure the specialist received the referral.
    • Confirm the patient attended the specialist appointment.

This guide provides an overview of how to manage superbills, HSAs/FSAs, identify billable services, handle typical fees, understand balance billing, and secure referrals. By following these best practices, you can ensure efficient billing processes and better financial management of your practice.

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