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Health Insurance Claim Form and Personal Injury Protection; Which boxes need to be checked?

Car Accident Attorneys in Clearwater, Florida

All too often I am asked questions in such as “What can I do to make sure my claim does not get rejected” The very basic answer to that question is, insurance companies are going to reject some of your claims as a matter of course. But what types of mistakes can you actually control?

This article looks at a very basic thing you can control, the information placed on a Health Insurance Claim Form. Better known as a HICF or HCFA (pronounced Hick-Fa) the HICF is the approved document for the Centers for Medicare and Medicaid Services (“CMS”). Also known as a CMS 1500 form. Essentially every person in medical billing and coding is familiar with this document.

Florida Statute 627.736 (Florida No-Fault Statute) requires all Florida drivers to have PIP coverage. The statute reads:

(1) REQUIRED BENEFITS.—An insurance policy complying with the security requirements of s. 627.733 must provide personal injury protection to the named insured, relatives residing in the same household, persons operating the insured motor vehicle, passengers in the motor vehicle, and other persons struck by the motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle, subject to subsection (2) and paragraph (4)(e), to a limit of $10,000 in medical and disability benefits and $5,000 in death benefits resulting from bodily injury, sickness, disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as follows:

The most important part of the required benefits portion is to note the section that I bolded “struck by the motor vehicle”. Meaning the patient or yourself only gets afforded PIP coverage if they were in a motor vehicle accident. So how does the requirements and the HICF coincide?

A standard HICF form has 33 categories of boxes to be either filled in or checked off. Some boxes have sub-parts, but there is only one box that can indicate whether this person was in an auto accident or not. THAT IS BOX 10b.

What happens if box 10b is not checked:

What you are indicating as a biller when box 10 is not checked for yes under AUTO ACCIDENT? is that the services you performed were not auto accident related. Therefore, the insurance company, if they have an inexperienced adjuster or an adjuster who is looking for any reason not to pay a claim, will deny the claim under PIP. This would result in no payments to the medical facility.

A reminder as well that under the PIP law, there is no requirement for them to hold benefits for your claim to fix any issues. If they pay out the full $10,000 to other providers who did check box 10b, then your company will be out of luck. For more information on benefits exhaustion see: https://www.dolmanlaw.com/pip-benefits-exhausted/

What can I do to correct the error?

A lot of people will try to resubmit the billing to the insurance company. What usually happens is that they have to print a new HICF, which prints a new date on box 31. Therefore, when it is submitted, the insurance company will then deny the claim for untimely billing. For more information on untimely billing see: http://dolmanlaw.blogspot.com/2016/08/untimely-billing-in-personal-injury.html

The best course of action is to have good notes on all the treatment you did. Most initial evaluations (CPT Code 99202, 99203, 99204, and 99205) are followed with SOAP notes that describe that the person presented as “a result of a motor vehicle accident”. Therefore, if your notes had indicated to the insurance company that this was indeed related to a motor vehicle accident, it can be argued that they were put on constructive notice and you substantially complied with the requirement and it is related to a car crash.

What do you do?

If you have been denied a claim because someone forgot to check box 10b, on the HICF, and you have substantial notes indicating that the injuries and treatment are indeed related to a motor vehicle accident, do not contact the insurance company and do not resubmit the bill. Reach out to Dolman Law Group. We will demand they pay you properly. If they do not respond by paying, we will sue them in a court of law.

Don’t play the back and forth game with the insurance companies. Contact Dolman Law Group at 727-222-6922 or derek@dolmanlaw.com and let us make them pay. This service will not cost you a dime. We get paid when you get paid by the insurance company.