FMBS Patient Insurance Submission Birth Center & Midwife for Mom & Baby Form

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Understanding the Claims Process- PLEASE READ

Claims are processed as follows:

Billed Amount for each CPT- The billed amount is based on the provider fees schedule

Allowed amount - Each plan has an amount that each CPT code is worth and has NO relation to the providers fee schedule

The difference between the billed amount and the allowed amount is called the provider adjustment

Patient Responsibility- Any responsibility like copay, deductible , coinsurance is taken from the allowed amount

Pay Out- any amount that is paid out is the difference between the allowed amount and the patient responsibility.

Example
CPT 59400 allowed amount is 2500.00 the billed amount is 5000.00
Patient has 500.00 in unmet deductible

59400 - 5000
allowed 2500
Write off 2500

of the allowed amount 2500
patient responsibility 500.00
payout 2000.00

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Understanding Claim Time Frame Processing- PLEASE READ

1. Claims submitted to FMBS
2. FMBS receives within 24 hours
3. FMBS submits to your insurance plan within 3 business days of receipt
4. Your insurance plan will receive and log the received claim within 14 business days of FMBS submission
5. Once your plan assigns a claim number, they have 30-45 business days for the claim to approve payment
6. Once payment is approved it takes 14 business days for pay out and check receipt

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Sender

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I Acknowledge receipt of the Claims Process & Time Frames* This field is required.

I Have read ad understood the clams processing and times frames

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What is the FIRST and LAST name of the Patient?* This field is required.

First Name

Last Name

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Patient Email* This field is required.

example@example.com

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I Acknowledge - select all that apply* This field is required.

My provider MUST be contracted/ IN Network IF my plan is an HMO/EPO/POS

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I Acknowledge - select all that apply* This field is required.

FMBS is limited in their ability to assist in properly submitted claims

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I would like to....* This field is required.

Move Forward with Billing

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What service are you submitting for?* This field is required.

Maternity Claim Submission (Mother)

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What is today's date?* This field is required.

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What is a good email for you? (the submitter)* This field is required.

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What is the Patient's date of birth?* This field is required.

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What is your address?* This field is required.

Street Address

City, State and Zip

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What is a good phone number?* This field is required.

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What is the name of your Midwife?* This field is required.

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What is your Insurance Plan Name?* This field is required.

(ie..Aetna)

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What is your Member/Policy ID #?* This field is required.

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Send us a FRONT picture of your insurance card (pdf, png, jpeg, jpg ONLY)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Send us a BACK picture of your insurance card (pdf, png, jpeg, jpg ONLY)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Where did you receive your prenatal care?* This field is required.

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What was the approximate date of your FIRST prenatal appointment?* This field is required.

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What was the approximate date of your LAST prenatal appointment?* This field is required.

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Did your Midwife provide prenatal care AND deliver your baby?* This field is required.

Yes, 59400 dx O80 Z370

No, 59426 dx Z3491

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Where did you deliver your baby?* This field is required.

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What date did you deliver your baby?* This field is required.

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Did you labor at the birth center before you delivered?* This field is required.

No

Yes, Labor Facility 0724 with 99236 dx O63.9

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List all the days you labored at the facility but did not give birth.

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Did you stay at the birth center AFTER you delivered?* This field is required.

No

Yes, PP Facility 0724 with 99236 dx Z39.0

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List all the days you stayed at the birth center after your delivery.

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Did you receive lactation care?* This field is required.

No, no lactation care billable

Yes, bill 99214 / 99403/ S9443 dxZ391

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List All the dates you received lactation care?

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What is the baby's FULL name?* This field is required.

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What is baby's date of birth?* This field is required.

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What is the baby's gender?* This field is required.

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Did baby receive care from the midwife?* This field is required.

No

Yes, 99203 dx Z00129

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What date did baby first receive care?

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Did baby receive follow wellness/lactation care?* This field is required.

No

Yes, 99213/99403 dx R6330

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List all the dates baby received follow up care

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Provide your Total Amount Paid for care & Related Notes* This field is required.

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Please provide a copy of your PAID invoice

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Please use the link below to submit payment.

Maternity Claim Payment Link

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Terms and Conditions* This field is required.