Free Medical Billing Training Practical billing & coding course

Lesson 04

Provider & Patient Setup

Credentialing, clearinghouse enrollment, fee schedules and superbills, plus the patient and insurance information you must collect before a claim can be filed.

Lesson 4 of 10 8 min 12 sec video Updated 2022-05-09

Before Sending Claims

Before filing a claim for the encounter with the patient, there are certain authorizations that must be obtained and information collected:

  1. Provider (physician) must be credentialed with insurance payers.
  2. Provider must be enrolled with insurance companies to send claims electronically.
  3. Patient personal information collected.
  4. Patient insurance information collected.
  5. Patient authorization for provider to submit claims on their behalf.

Practice Management Software Setup

Just about every healthcare provider uses a practice management software to manage their practice. There are hundreds available. Practice management and medical billing software are used interchangeably. Just about all of them can perform the same basic functions:

  • Scheduling patient visits
  • Managing patient accounts
  • Creating insurance claims
  • Recording insurance and patient payments
  • Creating patient statements
  • Tracking claim status
Lesson 4: Provider & Patient Setup 8 min 12 sec Screencast from practice management software

Example of Provider Setup Screen

Provider record in practice management software, showing provider ID, name, address, tax ID, specialty taxonomy code and NPI fields alongside insurance company PIN and group numbers.

Collecting Patient Information

In addition to setting up a provider, the patient information needed for filing claims must be collected. Below is an example of the patient information form used on the first patient visit.

Blank patient information form with sections for patient demographics, emergency contact details, and primary and secondary insurance, ending in an assignment of benefits signature line.

Patient Insurance Information

Most of the necessary patient insurance information is contained on their insurance card. Below is an example of the Blue Cross insurance card.

Front and back of a sample Blue Cross Blue Shield Federal Employee Program insurance card, showing member name, member ID, enrollment code, effective date and RxBIN, RxPCN and RxGrp pharmacy routing numbers.

CMS-1500 Form

  • The most important form in medical billing in both its paper and electronic form.
  • Contains all the information from the patient encounter in one form.
  • The CMS-1500 form was developed by the National Uniform Claim Committee (NUCC).
  • NUCC is responsible for standardizing instructions for completion of the form.
Blank CMS-1500 health insurance claim form, the standard paper claim used to bill professional services to Medicare, Medicaid and commercial payers.

Patient Information Screen Example in Practice Management Software

Patient insurance tab in practice management software, showing eligibility check settings and primary and secondary insurance panels for subscriber ID, group number, deductible, co-payment and prior authorization.

Example of Patient Encounter (Visit) Screens in Practice Management Software

Patient visit screen for a sample patient, showing the visit date, provider, place of service and the diagnosis and procedure codes attached to the encounter.

Below is the screen in the practice management software that includes the details of the visit. This is where the diagnosis and treatment codes are entered.

Edit Visit screen in practice management software, with ICD-10 diagnosis code slots, a billable line item grid for dates of service, place of service, CPT codes and modifiers, and a payment entry panel below.

Important Forms

The following forms are required on the first patient visit to obtain all the necessary information and authorization to bill for the visit:

  • Patient Information which includes Insurance, Guarantor, Assignment of Benefits, Payment Authorization
  • Authorization for Release of Medical Information
  • Patient Medical History
  • PHI Acknowledgment of Receipt of Privacy Policy
  • Payment Policy
  • HIPAA Communication Disclosure

MS Word templates of these and many other forms are included with the Medical Billing Fundamentals Course.