Filing a Claim Terminology

Alright, let's move forward with terminology as it relates to filing a claim. So, what is a claim? Well basically, it's a request for payment from the insurance payor, that we file on behalf of the patient, so that they do not have to pay full-service fees, as well as we get paid for the work that we do. Now, claims historically have been filed on a form called CMS 1500. We used to do all of this on paper and now, we file or we submit everything electronically. In fact, Medicare requires that you file electronically.

Next, we have the eligibility. Eligibility, what this is, is we call the insurance company or we go to their website or we utilize various tools that we may have available to us to confirm that the patient actually has benefit coverage available. Meaning, the insurance company is going to pay a portion of the fees for them, whether it be for a medical exam, a vision exam, and/or materials, such as glasses or contacts.

Now, the next one is eligibility date. This is important because this is the date that the patient's insurance became active. And if that patients say they for some reason, they lapsed on the payment and their insurance became inactive and they have not renewed, and they try to come in for an exam, and we provide those services, when we go to file their insurance and say we had not checked that they had insurance benefits. Well, what's going to happen is that claim is going to be denied. So, very, very important that we always call, that we make sure that they are eligible and we determine what their benefits coverage is and you’ll be set to go.