Admission Process: Authorization and Benefit Verification
Insurance verification and authorization plays a significant role in everyday life for a skilled nursing facility. Verifying insurance eligibility and receiving authorization is essential to avoid potential claim denials and patient ineligibility. Insurance verification and authorization involves validating the patient’s insurance details with the appropriate payer.
The verification process ensures verification of: payable benefits, patient details, pre-authorization process, co-payments, deductibles, policy status and effective dates. It will also include the type of plan, coverage and potential policy exclusions. There are three easy steps to insurance verification's, once the facility has confirmed they are contracted with the particular plan.
- Collect the patient’s insurance information. This will come in the form of the patients, name, date of birth along with the insurance company name. The policy number and group ID number will also need to be collected. A copy of the members card is a bonus.
- Contact the insurance company prior to admitting. If possible, initiate contact with the health plan 72 hours prior to the admission. The most preferable way is to utilize the health plans website portal and/or Availity. While phone numbers are available, they take more time, and most health plans require verification online.
- Gather all critical benefit information for admission to a Skilled Nursing Facility. If your company does not have a standardized insurance verification form, one can be found on the MCCFL portal.
While insurance verification can be time consuming or tedious, it is always best to avoid costly billing issues.
Previously, Simply was denying LTC claims due to QAO “explanation of benefits is needed from the Member’s primary carrier”. They were also denying claims due to G18 “the submitted service is not allowed per your contract” and 256 “service not payable per managed care contract.” These were “configurations” issues. According to our call today, these claims have been reprocessed or are currently being reprocessed. HOWEVER, we know that not all claims have been reprocessed, as some do get missed. If your facility still has outstanding claims due to these denials, please fill out the spreadsheet attached. **Note: only one facility per spreadsheet.
Regarding LTC claims that had patient liability issues, if you have submitted a claim, these ARE being worked. HOWEVER, per the reps, these claims take longer to reprocess, i.e. 45-60 days. For future patient liability issues, please complete the attached “simply recoupment notification form” and provide documentation supporting patient liability. The address to send this form to is located on page 2; a fax number is listed as well if you would rather send the information that way. **AGAIN, please allow additional time for the claims that you have submitted. For new claims, please use the attached form. The reps mentioned that they are working to correct the patient liability issues.
Effective Oct. 1, 2020, we strongly encourage you to document Social Determinants of Health (SDoH) using ICD-10 diagnostic code(s) (or successor diagnostic codes) in the member’s medical record. This applies to Medicare advantage, MMA, and group market plans.