Once you’ve opened a Medical Payments claim with your own auto insurance company, the next step is to submit your medical bills and records for reimbursement. However, this process is not as simple as faxing a copy of the patient bill you just received in the mail over to your adjuster. There are three main components to requesting your MedPay Reimbursement:
If you’ve ever had to request your medical bills and records in the past, especially from a large medical provider, such as a hospital, you know how challenging and time-consuming this can be. MedPay adjusters will only reimburse “reasonable” and “medically necessary” medical expenses up to the specified limit in your auto insurance policy. This means adjusters are going to be looking for very specific information that shows that the treatment you received was necessary in accordance with injuries sustained in an accident.
When you open a Medical Payments claim, your adjuster will send you a packet in which they list exactly what type of information they need in order to process MedPay reimbursement. While the information required will depend upon your insurance company, there are certain items you should always make sure are included. The best way to ensure you have the necessary information is to ensure you are requesting the right information directly from the medical provider.
The best way to request bills and records is to call each provider and ask them how they prefer that you request copies of these medical bills and records. You may be asked to come into the office or send a written request by email, fax or mail. You may also be required to sign a release or provide identification to confirm you are the one authorized to collect this HIPAA-protected information. In some cases, you may even be required to pay for copies of these bills and records. North Carolina law mandates that a medical provider can charge a “reasonable fee” to cover the costs of producing the records, but the maximum fee is 75 cents per page for the first 25 pages, 50 cents per page until 100 pages and 25 cents per page after 100 pages. Further, if you have a lien at that healthcare facility, North Carolina law prohibits that they charge you for any bills or records. If you do have a lien and they charge you for your records, the lien will no longer be perfected and may not be enforceable. For more information on perfected liens and how they may affect your settlement, click here.
It is also important to keep in mind that some medical providers have a separate billing department from their records department, so be sure to ask the customer service representative on the line if one request can be sent for both bills and records, or if you will have to make the requests to separate departments. The patient bills you receive will often just reflect the remaining balance. This is of no use to the adjuster, and if you send those bills, they will send them right back to you with a request for additional information.
If you do not provide the correct information, the adjuster will deny your request and ask that you correct what you sent. Regardless of whether or not the adjuster will accept the medical treatment, providing the correct documentation is the first step. Reasons they may not accept your request include:
A diagnosis code is the code provided by your medical professional that correlates with a particular diagnosis. For example, if you have been rear-ended and the emergency room doctors give you a diagnosis of whiplash and chest contusions, there will be a numeric/lettered code to represent each diagnosis. Your adjuster will use these codes to check if the code falls into a category that they would typically reimburse. For example, if you have been diagnosed with an ear infection during that same visit, the insurance adjuster is going to deny reimbursing that particular diagnosis.
Like diagnosis codes, procedure codes are provided by your medical professional and correlate with a particular diagnostic, medical or surgical procedure. For example, if you were seen at the emergency room and had to get x-rays of your cervical spine, there will be a numeric code next to that charge on your bill indicating the type of procedure you had completed.
On your bills and records, these codes may be referred to as “ICD-9” and “CPT” codes. Sometimes they are listed next to each date of service charge, and sometimes they are at the top of the bill. You may have to examine the entire billing statement to ensure these codes are included, and if you have any questions, the medical provider’s billing department should be able to point out the codes for you.
When you are sure you have collected all of your medical bills and records related to the accident, the next step is to submit them to the adjuster for reimbursement. This is probably the easiest step, as it is just a matter of putting the documents in order and sending them to the adjuster. If you have received any correspondence from the Medical Payments adjuster, they likely provided a fax number, email address and mailing address to which medical records can be submitted.
If you choose to fax your documents, it is recommended that you include a cover page addressing the fax to the proper adjuster. Make sure your claim number is on the fax cover, and it is a good idea to write the claim number on each additional page so that no pages get lost. Keep in mind that not all fax machines can handle the same amount of pages, so you may want to only fax your documents if they are 30 pages or less.
You do not have to submit documents for each facility at the same time. For example, if you have been treated at the emergency room and the chiropractor, you will need bills and records for both facilities. If you receive everything from the emergency room first, go ahead and get those sent so the MedPay adjuster can work on reviewing them for reimbursement. As long as you properly label the next set of documents you send, it will still get to the correct adjuster. The adjuster will keep reviewing your documents until they have maxed out the reimbursement amount. Just because they reimburse your emergency room visit does not mean they will close the claim if you still have MedPay money available to you.
If you have treated at several different facilities or have a large MedPay reimbursement limit, it may be extremely helpful to submit documentation by facility instead of all at once so that you can keep track of what you have sent and what has been reimbursed. Some companies will submit reimbursements in pieces, and it is much easier to track or follow up on a reimbursement if you know exactly what you sent and the exact date you sent it.
This phase of the MedPay reimbursement process is often the trickiest. There are several factors that come into play at this point that can affect your next steps, and they may impact how difficult reviewing your reimbursement becomes, including the amount available to you, the number of facilities you have been treated by and the extent of your treatment.
Ultimately, an insurance adjuster will do one of the following when medical bills are submitted for reimbursement: a) reimburse for the expense b) deny the expense c) partially reimburse the expense or d) ask for additional documentation. Depending on the action taken by the adjuster, a follow-up action by you is often required.
Which of the four ways the adjuster has responded will determine the appropriate follow-up action you should take next. If at any point in this process you are unsure about what has been reimbursed, ask your adjuster for a Medical Payments Log, which will reflect what has been paid out so far.
If your medical expenses do not exceed your MedPay reimbursement limit, the adjuster will confirm with you that there are no new treatment facilities or any outstanding bills you will be submitting, and they will close the claim. It is a good idea to match all checks and explanation of reimbursements up to the documents you submitted so that you can make sure you have not forgotten to submit a bill.
Once your entire medical payments reimbursement limit has been maxed out, the adjuster will close the claim and will likely send you a letter called an “exhaustion letter,” which states that you have no more MedPay available to collect.