Billing for Clinical Services


This is an archived project that was created in 2014. For more information about this project, contact [email protected].

Local health departments are facing shrinking federal, state and local budgets. Although public health has traditionally been free, the cost of providing preventive and clinical services such as immunization as well as HIV, STI, and TB testing has been growing for health departments. LHDs play an integral role in the changing landscape of the Affordable Care Act and will continue to provide services for their community.

Even with expanded insurance coverage, gaps will remain and LHDs will need to develop a way to provide services to insured patients as well as those left uninsured. In order for LHDs to be able to provide preventive and clinical services regardless of insurance status, they may need to develop the capacity to bill third party payers. LHDs should be compensated by billing Medicare, Medicaid and private insurance companies for immunization, HIV, STI, TB testing and care, and other clinical services.

This site should serve as a guide and a resource for LHDs in building capacity to bill third party payers for clinical services. Whether your LHD is just starting the process to be able to bill or already has contracts with private insurance companies, NACCHO’s Billing for Clinical Services Toolkit has resources, templates, and manuals to help with your process.

Where to Start

NACCHO's Billing for Clinical Services Toolkit was designed to help make navigating the billing process easier for local health departments. In this toolkit you can find resources, guides, and templates on all aspects of billing.

To access the Billing for Clinical Services Toolkit, please click on the “Toolkits” drop-down menu and select “Billing for Clinical Services.” There are more than 300 resources available. To download any of the tools, you will need to register or use your current log-in with NACCHO’s web site.

Toolkit Structure

Below is the structure of the toolkit based on the order of the billing process.

  • (01) Definitions, FAQS & Glossary
  • (02) Getting Started
  • (03) Laws and Regulations
  • (04) Workforce Development
  • (05) Clearinghouses
  • (06) EHR/EMR
  • (07) Medicaid/Medicare
  • (08) Private Insurers
  • (09) Credentialing
  • (10) Contracting
  • (11) Financial/Fee Policies
  • (12) Patient Intake
  • (13) Coding
  • (14) Coding Quality Assurance
  • (15) Claim Submission
  • (16) Billing Remittance Advice
  • (17) State Billing Guides
  • (18) Immunization Tools
  • (19) HIV Tools
  • (20) STI Tools
  • (21) TB Tools
  • (22) Other Clinical Services
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About This Tool

This resource was developed to help health departments (HDs) with varying knowledge, understand the billing for clinical services process. This tool will help users determine what is needed to build general billing capacity and easily access tools that best meets their needs.

Other Key Resources to Consider:

  • Health department peers and partners, community health centers, local hospitals, commercial labs, state insurance departments, state Medicaid and CHIP programs, and other medical practices who have knowledge of/experience with billing
  • State Billing Guides
  • Improving Reimbursement for Health Department Clinics Community of Practice (CoP) - an online portal for collaboration that allows members to access expertise and share experiences, success stories, tools, and ways of addressing barriers in planning and implementing billing systems
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Why consider billing for clinical services

a. Changing healthcare environment offers new billing opportunities

b. Public health financing

c. Understanding the landscape of the safety net in your jurisdiction

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How to decide if billing is appropriate for your health department

a. Assess HD infrastructure to bill for services

b. Consider state statutes or administrative billing regulations

c. Calculate costs and benefits to see if it makes financial sense to bill

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How to decide which billing approach makes sense (i.e. in-house or outsourcing)

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How to bill in-house

See Section Five: How to partially or fully outsource billing (below) to access tools for tools on outsourcing certain billing functions

a. Build billing infrastructure and utilizing staff

b. Establish fee schedules and clinic policies

c. Build Capacity for Coding

d. Develop Standard Operating Procedures (SOPs)

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How to partially or fully outsource billing

a. Select and contract with a medical billing service provider or clearinghouse

b. Build billing infrastructure and attain staff

c. Establish fee schedules and clinic policies

d. Develop Standard Operating Procedures (SOPs) - See Section Four d. Develop Standard Operation Procedures (above)

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How to get providers credentialed with a health plan

a. Understand the credentialing process

b. Identify credentialing requirements

c. Gather and submit credentialing documents

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How to enroll with public payers (Medicaid, Children’s Health Insurance Program (CHIP), and Medicare)

a. Access your State Medicaid and CHIP provider enrollment requirements

b. Access Medicare provider enrollment requirements

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How to contract as an in-network provider with private payers (Blue Cross Blue Shield, Aetna, Humana, etc.)

a. Understand the contracting (provider enrollment) process

b. Identify health insurance plan models available in your area

c. Send a Letter of Intent to payers

d. Determine if a contract is necessary

e. Review contract or provider service agreement and negotiate contracts

f. Approve contract

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How to develop a quality assurance program and maximize billing revenue

A quality assurance program can improve claims management, increase cash flow, assure compliance with applicable laws and regulations, and ensure timeliness and accuracy of billing and collections.

a. Develop a quality assurance program

b. Learn how to perform a medical audit

c. Develop a quality assurance compliance program

d. Improve billing efficiency

  • Training the billing staff and consulting with billing specialist/coding experts
  • Identify and address problem areas and inefficiencies in claims
  • Resubmit and manage denied claims - See "Management of Denied Claims" in Section Four d. Develop Standard Operation Procedures (above)
  • Determine if your HD should use an external billing company - See Section Three: How to decide which billing approach (i.e. in-house or outsourcing) makes sense and Section Five: How to partially or fully outsource billing
  • Review and update your SOPs - See Section Four. d. Develop Standard Operating Procedures (above)
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NACCHO Webinar: Becoming an In-Network Provider: The Health Department Perspective, November 2013

  • Speaker: Scott Coley, MS, MPH – New York State Health Department
  • Speaker: Robin Iszler, RN – Central Valley (ND) Health District
  • Speakers: Vicky Poirrier and Sharon Gates – Mississippi State Department of Health
  • Speakers: Various staff – NACCHO
  • Recording [YouTube link]
  • Slides [PDF]
  • Q&A session answers [PDF]
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