Fill and Sign the 1 Please Return This Completed Form to Butler County Children Butlercountychildrenservices

Medical Claims __________________________________________________________________________________________________________________ How to File a Medical Claim Coordination of Benefits Explanation of Benefits Instructions and Sample 07/01/2005 Visit our Website at http://mutualofomaha.com 1 How to File a Medical Claim The majority of providers will supply, complete and file claim forms for most in-network and out-of-network services. In the event that a claim was not submitted by the provider, please note the group number and name of the insured on the form and forward to the designated claims office. Coordination of Benefits (COB) The COB provision is designed to allow the maximum payment for covered qualified changes by coordinating benefits available between multiple plans. This also results in a cost savings for the plan, which is the second payer on the charges. This, in turn, can result in reduced premium costs. COB provides that for an employee covered under two or more plans, one plan will be primary and pay its normal benefits under the plan. Any other coverage(s) will be considered secondary and will pay up to the remainder left unpaid by the primary carrier. Like many Plan provisions, the COB provision is occasionally revised to keep up with the ever-changing health care environment. If you have questions about how COB works, refer to your Group Policy/Plan or contact your claims service representative. Medicare Handling Like group insurance plans, Medicare provides health care coverage to many elderly and disabled individuals. To reduce the risk of over-insurance, Medicare coverage is taken into consideration when determining what Plan benefits are payable. Medicare Secondary Payor Rules for Large Group Health Plans Prior to August 10, 1993, Medicare was secondary to group health coverage under a large group health plan for those individuals who were entitled to Medicare because of their disability and who satisfied the criteria for "active individuals" as established by the Health Care Financing Administration. Effective August 10, 1993, OBRA '93 amended the law to delete references to "active individuals." Under the revised law, if the individual is covered under the plan by virtue of his/her "current employment status," then the large group health plan may not take into account that the individual is entitled to Medicare. In essence, this means that the group plan will be the primary payor for disabled individuals who are actively employed. Medicare will be the primary payor for disabled individuals who are not actively employed. If your group health plan is no longer primary for a particular individual, then the Health Care Financing Administration requires you send a letter to the Medicare carrier in the state where your home office is located certifying the change. As we process claims, we will attempt to note these situations and notify you so that a letter may be sent. If you become aware of any change in an individual's status, please notify us so that we may note the change in our records. If you have questions about how your Plan works when Medicare is involved, contact your Claims Service Representative. 07/01/2005 Visit our Website at http://mutualofomaha.com 2 To file a claim when Mutual is the primary carrier…. Completed Claim Form Bill Bill Bi Bill The employee should file his or her claim with Mutual as usual. A completed claim form and copies of bills should be included. Remind the employee to make copies of bills to to file with the secondary insurance carrier. Bill . PRIMARY CARRIER (Mutual of Omaha) The employee may use the Explanation of Benefits (EOB) he or she receives from us to File with the other insurance carrier when they are secondary. SECONDARY CARRIER file with Explanation of Benefits Bill The employee should include copies of his or her bills to file with the secondary carrier as well. Bill ll 07/01/2005 Bill Visit our Website at http://mutualofomaha.com 3 To file a claim if Mutual is the secondary carrier…. Completed Claim Form Employees should submit: Copy of EOB from Primary Carrier 1. 2. 3. Bill Bill A completed claim form. A copy of the EOB from the primary insurance carrier (e.g., Medicare EOB, etc.) Copies of all bills to be considered for benefit consideration. Photocopies are acceptable. Bill SECONDARY CARRIER (Mutual of Omaha) Note: If Mutual of Omaha is the secondary carrier, we cannot consider benefits until the primary carrier has paid benefits and until we receive the copy of the primary of the primary carrier’s EOB Note: Follow the same procedures for coordination of benefits when Medicare is involved 07/01/2005 Visit our Website at http://mutualofomaha.com 4 Explanation of Benefits (EOB) Instructions and Sample Field The Explanation Of Benefits Field Descriptions Are Shown Below 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Field Name For Inquiries Call Date Page Direct Inquiries To Subscriber Group ID Provider Member Account No Claim No Reference No From Date To Date Service Type 18. Submitted Charge Negotiated Savings / WriteOff Charges Non Covered Note 19. 20. 21. 22. 23. 24. Note 2 Note 3 Note 4 Co-pay Ded. Co-Ins. 25. 26. Benefit Amount Patient Liability 27. 28. Claims Totals Total Considered Charges Other Carrier Paid Balance Coordinated Benefit Patient Liability 17. 29. 30. 31. 32. 07/01/2005 Description The toll Free and Local phone numbers to use for customer service. Date the claims were processed. Page Number. The company name and the claims paying office. The subscribers name. The Group ID. Name of the provider rendering services. Name of the member the claim has been processed for. The patient account number provided by the provider of service. Claim number assigned by company. Unique ID number assigned at the claim level on subscriber’s EOB. Beginning date of service. Ending date of service. Short description of the type of service rendered. For hospital claims submitted with revenue codes, the services will be shown as Room & Board, IP Misc or OP Misc The amount that was charged for the service. Dollar amount patient is not liable for. Includes: Clinical Editing when the plan and provider are PPO, Per Diem Claims, PPO Negotiated Savings, Multi Plan, Up & Up, Concentra, Risk Withhold, etc. Charges not covered due to policy exclusions, Usual and Customary reductions, plan limitations are also listed in this field. The patient is liable for amounts displayed here. A two- or three- digit alpha/numeric code for which the reason charges were not covered. If additional reason codes are needed, we can display up to 4 codes. If additional reason codes are needed, we can display up to 4 codes. If additional reason codes are needed, we can display up to 4 codes. Member co-payment amount. Amount applied to the deductible. The difference of the allowable amount after the negotiated savings, non-covered charges, copay and deductible have been taken. This is the percentage difference that is the patient’s responsibility. The amount payable by our plan. Patient out of pocket expenses. Includes non-covered services, co-payments, deductible amounts and coinsurance amounts. This amount may be reduced by the Coordination of Benefits with a Primary Carrier. Column amounts for each field when more than one line item exists for a claim. Total amount allowed by the primary insurance carrier. Amount primary carrier paid Difference between what the primary insurance carrier allowed and paid. Amount secondary carrier will be paying. Field will reflects patient’s liability after coordinating benefits with the primary carrier. Visit our Website at http://mutualofomaha.com 5 Field 33. 34. 35. 36. 37. 38. 39. 40. 41. Field Name Description after Coordination of Benefits Note: Fields 28-32 will only display on the EOB when coordination of benefits has occurred. Payment Total amount paid to the subscriber for the claim. Summary: Subscriber Amount Provider Amount Total amount paid to the provider for the claim. Deductible Deductible yet to be satisfied for participating and non-participating providers. Information Note Descriptions A detailed description for any notes associated to a line item. Negotiated Negotiated savings amounts will not have a NOTE printed on the line item. When Savings/Writeamounts display in this field, a generic message will print at the bottom of the Off Message subscriber’s EOB. “Savings negotiated by The Mutual of Omaha Companies with your provider of service. You are not liable for this amount. Patient Liability Generic message printed at the bottom of the EOB. Package ID The package ID number is used internally to access material. Fraud Language Fraud language will print based upon the state where the subscriber resides. If the state mandates special wording, it will be pulled in otherwise a generic fraud statement will print. Appeal Language Appeal language will print based upon the state where the subscriber resides. If the state mandates special wording, it will be pulled in otherwise a generic appeal statement will print. 07/01/2005 Visit our Website at http://mutualofomaha.com 6 07/01/2005 Visit our Website at http://mutualofomaha.com 7 07/01/2005 Visit our Website at http://mutualofomaha.com 8