The Business of Therapy

Before you send the claim.

A short pause to check the details—and the instructions that apply to this payer.

A claim is a request for payment, not a promise of payment. CMS identifies the CMS-1500 as the professional paper claim form used when paper filing is permitted. Electronic submission has its own requirements. Your software’s “send” button is the last step of preparation, not the whole process.

A practical review

Use these questions as a starting point alongside the payer’s current submission guide. This is not a complete claim specification.

  1. Right person, right plan?

    Compare the member and subscriber details with the current insurance information. Confirm which payer should receive the claim.

  2. Right provider and location?

    Review billing and rendering provider identifiers, service location, and the information the payer has on file.

  3. Does the claim reflect the service?

    Check the date, procedure and diagnosis information, units, charges, and any applicable modifiers against the documented service and payer instructions. Do not select a code simply because it pays more.

  4. Have you checked the plan’s requirements?

    Look up coverage, any referral or authorization requirements, filing deadlines, and the appropriate submission route. Do not borrow another payer’s deadline.

  5. How will you know it arrived?

    Keep the submission reference in your secure practice system. Review acknowledgments and subsequent payer responses; sending is not the same as acceptance or payment.

What to confirm with your payer

Ask for the current provider manual and electronic claim companion guide. Confirm any unclear field or submission rule before relying on a general example.

Primary sources & scope

CMS describes Medicare requirements. Commercial payer, plan, state, and service-specific rules can differ. The questions above are editorial review prompts, not a guarantee of reimbursement.

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