Welcome!

Here you will find out the general information on the different types of insurances that your patients have and that you must know about to perform your duties as an Insurance Clerk.  This information should be know to everyone in the Accounts Receivable area from the Front Office, registration, back office, billing, collection and posting personnel.  You will be able to click on the various headings in the columns to be taken to a more in depth information page.

GOVERNMENT PROGRAMS	Medicare	Medicaid	Tricare
Insurance Card Samples
General Overview	Medicare is a Federal Government sponsored insurance.	Medicaid is a State Government Sponsored Insurance	Tricare is an Insurance for Military personnel and their covered dependents
Copays, Deductibles and Coinsurance	At the Beginning of the year each insured person has a $135 deductible due for outpatient/doctors office visits then 20% of approved amount.  For Inpatient there is a $1024 admission copay every 60 days	Most plans offered by the State do not have any copayments, deductibles or coinsurance amounts	Generally they have a $150 annual deductible with either a 15%, 20% or 25% coinsurance on most services based on Tricare Extra, Standard or Retired Benefits
Non-Covered Expenses	There is a list of services not covered by Medicare in the Medicare and You Handbooks	Generally, all services are covered unless otherwise specified by the plan the patient is participating with	Most services are covered at the local base hospital if there is a referral or "non-availability form" on file then the patient can seek outside services
Covered Expenses	Regular Medicare covers most expenses in a doctors office, outpatient and inpatient stays up to certain limits	All services not specifically not covered are limited by the yearly maximums within the plan	Generally any service that is available on the local military base facility.

 

Group Health Insurance	HMOs	PPOs
Insurance Card Samples
General Overview	These are generally employer sponsored plans that have restrictions on where and who can perform the services for the patients.	These plans are also generally sponsored by the employers and do not have as many restrictions as to who can perform the services.
Copays, Deductibles and Coinsurance	HMOs almost always have copayments due for all covered services.  There are generally no deductibles or coinsurance amounts.	PPOs may have a copay due on certain services and almost always have a yearly deductible and coinsurance amounts due based on the contracted rate for that particular service.
Non-Covered Expenses	Any service that is listed in the non-covered section of the patient's booklet AND those services that do not have a referral such as going to a doctor who is not their assigned primary MD.	The Non-Covered services will be listed in the patient's booklet.  Generally, they are not required to get a referral from their primary care physician but must go to a doctor or facility that participates in their network
Covered Expenses	These can vary by plan and by employer.  The actual covered services are listed in the patient's booklet	As with the HMOs these services vary by plan and employer.  The actual covered services will be listed in the patient's booklet.

 

Regular Insurance and Supplements	Commercial & Indemnity	Medicare and Tricare Supplements
Insurance Card Samples
General Overview	Commercial and Indemnity Plans general are non-contracted insurances that pay a certain percentage of the total bill with the patient responsible for the balance.  These services have no restrictions on who or where the services are done.	Supplemental plans will generally cover the remaining patient due balance only after Medicare and Tricare have processed the claim
Copays, Deductibles and Coinsurance	The patient will more than likely have a yearly deductible as well as coinsurance percentage due on every visit and service	Most plans cover the remaining balance after the primary insurance has paid however a few will require that the patient pays the yearly deductible.
Non-Covered Expenses	Those will be listed in the patient's plan booklet	Generally will not cover anything that was not considered by the primary insurance
Covered Expenses	Those will be listed in the patient's plan booklet!	Generally everything is covered that is normally covered by their primary insurance

 

 

Special Insurance Coverages	Auto Insurance	Workers Comp Insurance
Sample Insurances
General Overview	Automobile insurance coverage for medical expenses various from state to state.  You will need to find out if your state is a "No-Fault" state.  However, in general when the patient is receiving services for injuries due to an automobile accident then the Auto Insurance will be primary over all other insurances	When a patient is injured "On the Job" the employer is legally liable for any medical care that is required and authorized for payment.  There are specific requirements that must be met and each state has it's own regulations regarding the information required for payment processing.   No other insurances can be billed for the services related to workers comp injuries.
Covered Services	Only those expenses arising out the treatment for injuries relating to the automobile accident itself are generally covered.	After the initial injury treatment all further treatment must be authorized by the W/C claims adjustor.  Anything authorized and related to the diagnosing and treatment of the injured employee is covered.
Non-Covered Services	Any services not related to the automobile accident injury.  Most automobile insurance plans have a high deductible and a limited amount of medical coverage thus once the automobile insurance carrier denies the claim or applies any portion to a deductible the balance can be sent to the patient's regular medical insurance for payment	Any services not related to the injury.  And any services other than emergency medical treatment related to the injury that was not authorized.