Pay close attention to the information you give your healthcare provider at registration. Answers to those questions are sent to your insurance from your provider. Without the correct answers, you may become responsible for the balance.
Have you ever been in the waiting room at a doctor's office and heard this conversation?
Patient: “My name is H I, and I have an appointment at 10 this morning with Dr. Smith.
Receptionist: “Great! I see you on the schedule. Please take this clipboard and fill out these registration forms, and I'll make a copy of your insurance card when you come back.”
Patient: “Why do I have to fill them out again? Don’t you already have this information? “
Receptionist: “Yes, we do, but we need to make sure all information is accurate and current.”
It may seem ridiculous and redundant, but in fact, it is very important. One incorrect item can get your claim delayed or even denied. When filling out your registration form, make sure you fill in every field that pertains to you.
Answers that Can Get Office Visit Claims Rejected by Insurers
Your Name
Let us pretend your birth name is Henry Blynn Jones III, but your dad goes by Henry, and your grandfather goes by Blynn, so you go by HB. It is not your legal name, but it is the name everyone knows. You want to use your nickname at the doctor's office. In the field for your first name, you write "HB". Although you may want to use your nickname, your medical record is considered a legal document. Your legal name should be used on your chart, whether it is a paper chart or electronic.
Do not worry, the provider's office has workarounds to ensure they use your nickname. Most electronic medical record software has a field to enter your nickname or preferred name, and it will be displayed on your chart. On paper charts, it is more than likely that the front office has put your nickname in parentheses next to your legal name, to remind everyone that your legal name differs from your nickname.
Because a provider must file a claim for the person they saw, they must use your legal name. Your insurance may deny the claim as "member not found" because their records don't match the name given by the provider. Medicaid and Medicare are known to deny the claim when names don't match. It is in your best interest to have your name on your State ID, your health insurance card, and your medical record match. Do some providers and health insurance companies allow you to use your preferred name? Yes, but not all. Rather than keeping a list of who allows it and who doesn't, write your legal name and your preferred name in another field.
Your Insurance Information
Give your provider as much information as you can regarding your insurance. When you see a provider and expect another entity (your insurance) to pay for your care, you want to give your provider all the correct information. Remember that the promise that your insurance will pay the provider is a contract between you and the insurance. Your provider, in good faith, is accepting partial payment from you for the services they render to you. In order to request the rest of the payment from your insurance company, they will need all the necessary information to file a claim for you.
The best way to give them your current, correct information is to take your card with you to your appointment. The front office will scan a copy of it and will enter it for you. If you do not have your insurance card, a very common problem at the beginning of the year when insurance plans change, you will need to provide them with the information. At minimum, they will need the name of the insurance, claims mailing address, phone number for providers, member identification number, group number (if applicable), and the name and birthdate of the primary member on the plan. If you cannot locate your card or have not received it yet, and your plan is through your employer, your human resources department should be able to help you obtain this information. If you have online access to your insurance, you can find this information online.
Your Secondary Insurance Information
It is possible to be covered by more than one insurance plan. This is known as having dual coverage. It is in your best interest to give your provider information for all your health plans. It is possible that one insurance company already knows about the other insurance and is expecting your provider to file your claim in the correct order. Failing to do so may result in a denial. The correct order to file is called coordination of benefits. Your provider will need to enter both plans on their claim and file them in proper order. The claim must go to the primary insurance first, and the response from the primary insurance is sent to the secondary insurance if there is a remaining balance. The member cannot choose which plan is primary. There are industry standards and regulations that determine which insurance is primary. For instance, Medicaid is always secondary. If a dependent is covered by both parents, there is a birthday rule to determine which plan is primary unless there is a court order that states otherwise. Because insurance companies can obtain historical information about your other policies via the member, their database, or from a third-party company, they will deny the claim from your provider if they do not send the response from the primary to the secondary.
It is important to give all the information because the provider will call or go online to verify your benefits with the insurance. Many insurance companies have similar names, or the main address to send claims is different for your group plan. Your insurance may require a referral or authorization before being seen by a provider. The provider office will do its best to get the insurance verified, follow its guidelines, and send the claim for you. Help them help you.
Referred By
If you have made an appointment with a provider because another provider referred you to them, supply that information to the provider. Enter the full name of the provider that referred you and their specialty in the “referred by” field. There are certain instances for commercial and government plans in which a provider must list the referring provider on the claim. For instance, the provider has been asked to consult on a patient. They will send a claim for a consultation and will need to send the referring provider's identification number, known as an NPI. The office will look up the number, but they need the name and specialty of the referring provider in order to search for it. Medicare and Medicaid insurance frequently need the referring provider's number in order to process a claim. If your insurance plan requires a referral form or authorization, the provider will need to contact them to obtain it. If they can’t get the referral before your appointment, to ensure the best benefit level for you, they may ask you to reschedule your appointment. Rescheduling your appointment is inconvenient for you, but it may save you money.
It is not that the other fields are unimportant. But these are the most common fields that can get your promised payment from your insurance to your provider in a timely manner. The great news is that many providers now offer online registration for your appointment. When you do online registration, you can fill it out at your own pace and ensure that you have completed registration with the best information that you have. It also allows your provider to do their due diligence to verify your insurance and inform you of any issues or questions they may have about your coverage. The last thing you want to do is take time off work and drive to an appointment, only to be told that you have to reschedule because there was an issue with your insurance that prevents the insurance from paying their portion. Or even worse, see the provider, leave the office, and receive a bill in the mail because your provider needs more information from you.
What to Do if You Receive a Bill
- If the statement states your insurance cannot ID you as a member, compare the information on the provider's statement and make sure the ID numbers and patient name match.
- If they do not match or the statement does not provide the information the provider used to file your claim, call the provider's office and speak to their billing department, and ask them to update your insurance information and to file the claim with the new information.
- If the information on the statement is correct, call your insurance company and ask them to review the [date of service] with Dr._______ and ask them why the claim was denied. Once you receive your answer, ask them what the next step is to take to have the claim reprocessed, and follow their instructions.
- If your visit was denied for no referral, call your insurance and ask if they have a referral on file. If they do, explain to them that your doctor is sending you a statement because there is no referral. Ask them to reprocess the date of service with the referral they have on file. If they do not see a referral for the date of service, you may be able to obtain a back-dated referral that will cover visits that have already occurred. Call the number on your statement. Speak to their billing person and tell them you spoke to [Name] at your insurance company, and let them know what the insurance said. If your insurance allows them to get a backdated referral, ask them to please get one and have the claim reprocessed.
- At the end of any call with your insurance, ask the customer service representative for their name and a reference number for the call. If the statement isn't resolved, you can call the insurance back and give them the name and reference number for the previous call. Many times, your insurance will state they show no record of a call, but if you give them the reference number and name of the person and the date you spoke to them, they can retrieve the history of your calls.
It may seem as though you are doing a lot of footwork, but it is best to be proactive if you are receiving a bill. Most providers have you sign a paper at the front desk stating you agree to pay any balance your insurance did not pay. However, the federal government and some state governments have put some protections in place for patients/consumers.
No Surprises Act
In 2022, the federal government enacted the No Surprises Act. It offers some relief from medical bills. It focuses on seeing out-of-network doctors when you receive emergency care. It even has provisions for people who have no insurance or who have self-pay care. You can learn more about it at CMS.gov (the Centers for Medicare & Medicaid Services website). There, you can get more details based on your situation and how to file a payment dispute. Some states have similar acts in place. Some states offer more protection, and some offer less. However, if they offer less protection, you can dispute your balance based on the federal No Surprises Act.
Texas also has protection at the state level. You can learn more about it at the Texas Department of Insurance website. In Texas, your healthcare provider must submit an initial itemized statement to the patient or the person responsible for the patient within 30 days of receiving the payment and/or denial from a third party, such as your insurance. If your healthcare provider sent an initial request for payment from you past the 30-day deadline, you can refer them to House Bill 185,, opens a new window which lists the 30-day provision.
Introduction to US Health Policy
Blue Cross Blue Shield Coordination of Benefits policy
United Healthcare Coordination of Benefits policy
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