Billing > Billing

Billing with providers information with an Auth


When billing claims on a CMS1500 form, If I have a provider that we have a Single Case Agreement or Out of Network Exemption done for them; What box determines that "In Network Status" would it be the information placed in box 25 and 33 as well as their information in 24j? What is the determining factor when claims get sent to the insurance to pull the information other then the Authorization number being put in?

Box 27, accepts assignment might be an option,  check 'yes' if appropriate.  That is the only field I'm aware of that might indicate this.  However, they have the agreement on file so it shouldn't be a problem.

The provider was contracted in a group contract and has since moved from that location. Unfortunately the insurance company is no longer taking provider/ group applications in our area, so we have got Out of network exceptions. So far, all claims I've been billed out have been getting paid out of network, i know that things can be missed but its happened with most of them. I'm just trying to make sure I didn't do anything wrong on my end as I am new to all of this.

I would contact them and ask if there is somewhere you are supposed to indicate that this is a single case agreement.  There may be something that you need to do to indicate it, or they may just be processing them wrong.


[0] Message Index

Go to full version