Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 12

Commercial Insurance

Copyright © 2008 Delmar Learning. All rights reserved.

2

Introduction

• This chapter is going to be talking about how to complete fee-for-service claims

Copyright © 2008 Delmar Learning. All rights reserved.

3

Processing Commercial Claims

• Separate instructions for primary, secondary, and supplemental commercial insurance plans.

• Instructions in a table format for completing claims.

Copyright © 2008 Delmar Learning. All rights reserved.

4

Processing Commercial Claims

• A case study and completed claim to illustrate the instructions

• Give a plain and a completed claim to the students to practice completing a claim

• Completed claims allow the students to receive feedback

Copyright © 2008 Delmar Learning. All rights reserved.

5

Commercial Claims

• Determined by one of the following criteria:– Patient is covered by one commercial plan – Patient is covered by a large employer group

health plan and also Medicare beneficiary – Patient is covered by a small or large

employer health plan and is the policy holder• Patient is also listed as a dependent on another

EGHP

Copyright © 2008 Delmar Learning. All rights reserved.

6

Commercial Claims

• Determined by one of the following criteria: – When the patient is a child who is covered

by two or more plans – Primary policyholder is the parent whose

birthday occurs first in the year

Copyright © 2008 Delmar Learning. All rights reserved.

7

Commercial Secondary Coverage

• Changes are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health insurance plans.