Orthotics and Prosthetics Billing Services

Prosthetics & Orthotics coverage may be subject to a copay or coinsurance. Authorization is required for various devices and this varies from payer to payer. This is considered a part of the member’s benefits provisions. For Prosthetic & Orthotics devices to be covered, a few of the general billing requirements are:

  1. A prescription from the ordering physician dated prior to delivery date.
  2. Consideration of limitations based on time period within which the item can be covered if supplied earlier.
  3. Appropriate modifiers must be billed, e.g. KX, LT / RT, NU etc.
  4. Coverage of devices also subject to qualifying diagnosis, e.g. orthotic shoes are not covered unless diagnosis states diabetic
  5. Repair, replacement and supplies may be eligible for separate reimbursement

Providing billing services for Prosthetics & Orthotics can be a time-consuming and wearisome affair. Among other things, it requires in-depth knowledge of reimbursement guidelines of Medicare, Medicaid and Commercial Plans, and their caveat. It also requires a constant devotion to quality and staying updated of all the changes happening in reimbursement regulations and coding & documentation requirements.
O&P BILLING Sunknowledge

With GoTelecare’s panel of highly knowledgeable billing experts, you can rest assured that your orthotics and prosthetics billing is in good, capable hands. Boost revenue with fewer denials and increased accounts receivable collection. Contact us for further details today.

A/R Analysis


Initial Visit Appointment Setup (done by Practice)
Order Entry

  • Patient Account Creation
  • Patient’s demographic entry
  • Prescription information entry

Initial Eligibility Verification

  • Creation of Insurance verification form
  • Checking general eligibility and benefits information
    and updation in OPIE

Initial Evaluation Appointment (done by Practitioner)

  • LCodes assignment
  • Measurements (If required)
  • Creation of Evaluation form/Notes/Other Medical Records

Detailed Eligibility Verification & Authorization Requirement Checking

  • Re-verification of eligibility with assigned codes
  • Updating detailed code specific benefits
  • Checking authorization requirements (Code Specific)
  • Creation of Service Estimates (Payer Specific and Reasonable
    and Customary)
  • Sending detailed written order/diabetic verification form and
    other paperwork to doctor’s office for signature

Doctor’s Office Follow-up

  • Contacting doctor’s office for pending detailed written order/
    diabetic verification form and other paperwork

Authorization/Pre-Determination/Referral Initiation

  • Creation of Insurance Authorization Form
  • Requesting Authorization/Pre-Determination/Referral
    (Via Phone/Fax/Email)

Authorization/Pre-Determination/Referral Follow-up

  • Follow-up with payer on Authorization/
    Pre-Determination/Referral status
  • Completion of authorization form based on the
    outcome of the request

Final Eligibility Verification or Pre-delivery Check

  • Creation of patient financial responsibility form
  • Notes updating
  • Work In Progress (WIP) updating

Office Coordinator Notification

  • Patient responsibility
  • ABN creation

Schedule Delivery

Delivery (done by Practice)

  • Signing Delivery Ticket (Soft copy/Hard copy)

Claim Submission

  • Primary/Secondary/Tertiary claim submission
    (via paper/fax/electronic)

Rejection Management

  • Online rejection checking (via Clearing House)
  • Correction and resubmission of the rejected claims
    (via Clearing House)

AR Follow-up & Denial Management

  • Follow-up on pending AR balance and working on denials
  • Follow-up on possible reconsideration requests
  • Filing reconsideration requests & appeals

Payment Posting

  • Patient payment posting and adjustments
  • Insurance payment posting and adjustments


Order entry based on the Rx received from the physician

Patient demographics & insurance entry

Submission of EDI / paper claim to payers

Rejection & Denial Management

A/R follow-up

Orthotics and Prosthetics Billing

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