Reading Payer Contracts for Key Medical Billing and Coding Details

Part of the Medical Billing & Coding For Dummies Cheat Sheet

Insurance companies (payers) offer various levels of coverage to their members, and as the medical biller/coder, you must be able to navigate payer contracts to gather the information you need to prepare and follow-up on claims. Many payers or networks have standardized contracts that they offer to healthcare providers. A well-defined contract does the following:

  • Defines the number of days after the encounter that the provider has to submit the claim. This is called timely filing.

  • Specifies how many days after receipt of the claim the payer has to make payment.

  • Specifies which of the payer plans are included, the frequency of services that it will cover (for certain procedures), and the type of claim that providers must submit.

  • Identifies special circumstances, such as how unlisted procedures will be reimbursed, which procedures are carved out of the fee schedule, the number of procedures that the payer will pay per encounter, and how to apply the multiple procedure discount.

  • Identifies the appeals process.

  • Identifies cost-intensive supplies or procedures (such as implants, screws, anchors, plates, rods, and so on) that may need to be paid.

As a biller/coder, make sure you're familiar with the contract specifics, and if you have any questions, talk to more experienced billers and coders in your office or call the payer directly for clarification.

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Medical Billing & Coding For Dummies Cheat Sheet

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