How Do Insurance Claims for Massage Work?
Massage therapy is an amazing, life-altering treatment for our Veterans, and we appreciate your choice to provide this service to those who served our country and are in need of medical massage treatment.
Have you ever wondered what happens after you treat the Veteran and submit your SOAP notes? Or why an NPI number is required to perform medically prescribed massage? Read on to learn what happens behind the scenes—and what it means for you as a medical practitioner.
What’s in a Claim?
For every massage you perform on a Veteran, a claim—a request for the insurer to pay for something—is sent to one of the VA’s two insurance carriers, Optum or Triwest, depending on where in the country the treatment was provided. Optum and Triwest are also known as third party payers, or TPA’s.
A claim cannot be submitted until the SOAP notes for the appointment are completed and signed by you, the provider.
Each claim is billed electronically using a HCFA 1500 form provided by the Centers for Medicare and Medicaid Services (CMS). It includes the following information:
CPT (Current Procedural Terminology) code - Every service available across the healthcare spectrum, from a check-up to a surgery, has a CPT code assigned to it. CPT codes are used uniformly across the entire healthcare industry to make the billing process consistent and to reduce errors. The code for massage therapy is 97124. 97124 is also a timed code, which means it is billed in units of time. A 1-hour massage treatment consists of four 15-minute units.
Diagnosis code - This is provided by the Veteran’s prescribing physician in his or her original referral from the VA.
Name & NPI number of the practice or company - In this case, ZP Medical Services, Zeel’s clinical affiliate.
Name & NPI number of the rendering provider - That’s you!
Supporting clinical documentation - This includes the SOAP notes you completed for the appointment.
How is a Claim Submitted?
Zeel completes the HCFA 1500 form containing all the claim information above and submits it electronically through a clearinghouse. This is a digital hub that allows healthcare practices to transmit electronic claims to insurance carriers securely.
An additional function of the clearinghouse is to flag errors or missing information on the claim, such as date of birth or gender. If such an issue is found, the clearinghouse will return the claim to Zeel to be reviewed, corrected, and resubmitted. Once the claim is approved by the clearinghouse, it is automatically routed to the appropriate TPA.
What Happens When the Insurer Receives the Claim?
When an electronic claim is received by an insurer—in this case Optum or TriWest—it is reviewed again by that entity. The insurer can then either remit payment for the claim or, if any data is incorrect or missing, reject it and send it back to the clearinghouse for correction.
Once a claim has been accepted, it is considered a “clean” claim. The insurer then determines their financial responsibility for the payment to the provider (total, partial, or none) in a process called adjudication. If the insurer agrees to the payment, it is then sent to the practice as an electronic remit. The practice will also receive an electronic remittance advice (ERA) through the clearinghouse, explaining the details of the payment.
More Than Just Paperwork!
Although this process is simple when it works, it can take up to 30 days for us to receive payment from insurers. And as you can see, many things have to go right for a claim to be paid. It takes a team working together, and an integral part of that team is you, the provider!
You steward the crucial first steps of the claim process by setting up your NPI number correctly, keeping professional SOAP notes, and, of course, providing an essential medical service. We rely on you, your decision-making, and your professionalism to help us make every claim a success.