Medical Billing Terminolgy

Medical Billing Terms And Definitions:-

What is Medical Billing?
     It is the process of sending the Claim forms (CMS form 1500) to the Insurance Company on behalf of the provider office.

EOB (Explanation of Benefits)?
The statement of response which we received from the insurance company after submit a claim.
(OR)
EOB is the statement received from the insurance company.

DENIAL:
It is a statement received from the insurance company stating that they are not going to pay the claim and that statement is called "Denial".
(OR)
It is the information mentioned in denied claim EOB.

CPTCODE (OR) CURRENT PROCEDURAL TERMINOLOGY:
The treatment done by the provider to the patient is converted in to alpha numeric code is called “CPTCODE”.
CPTCODE range is 5 digits.
(OR)
CPT CODE reprents provider service.

In CMS-1500 form, CPT CODE located at Block No: 24D

Reference Book for CPT Code:  Healthcare Common Procedure Coding System (HCPCS).

It is the codes which specifies range for a specialty of provider
Specialty             CPT Code Ranges and Values
Office Visit ------------------------->:   99201 - 99499
EM (Evaluation and Management Services):-
Anesthesia  ------------------------->:   00100 - 01999
Surgery------------------------------>:   10000 - 69990
Radiology (X-ray, Scanning)---->:   70000 - 79999  
Pathology & Laboratory--------->:  80000 - 89398
To check up medicine------------->:  90281 - 99099

DIAGNOSIS CODE (OR) DX CODE:
The disease or illness of the patient is converted in to alpha numeric code is called “DIAGNOSIS CODE”. Its range is 7 digits.
(OR)
DX CODE represents the Patient Disease
In CMS-1500 form, CPT CODE located at Block No: 23
Reference Book for DX Code:
ICD 10CM (International Classification of Disease of 10th revision Clinical Modification).
It is effective from October 2015.Before that ICD 9CM was used

DOS (Date of Service)
It is the date when the treatment was taken by patient.
DOS MENTIONED IN CMS 1500  - Block 24A

REVENUE CYCLE MANAGEMENT:

The total process from Retrieving of files to AR follow up is called "RCM".

CAN YOU EXPLAIN RCM FOR ME? (OR) CAN YOU PLEASE TELL ME THE STEPS INVOLVED IN RCM?
ANS: It include process like
1 Retrieval of files from clients system.
   The next process is
2 Patient Demographics
   And after this
3 Medical Coding
4 Charge Entry
5 Transmission of claims or  patient bills
6 Cash posting and denial documentation
7 AR follow up( ACCOUNT RECEIVABLE) ------>DESIGNATION --   AR CALLER

MODIFIER:-
It is alpha numeric code that gives extra meaning to the CPT code.
BLOCK NO OF IN CMS 1500 FORM    - BLOCK NO 24 D

What are the modifiers you used in your previous office or tell me some modifiers what you know?
ANS: We have used modifiers
26-It represents physician services
TC-It represents Technical Component services
LT-It represents service done for left side organ of body
RT-It represents service done for Right side organ of body
59-It it is distinct service
76-It represents same service done twice by same provider
77-It represents same represents service done twice by different provider

Social Security Number (SSN):
It is a nine digit unique number issued to US citizens (permanent residents and temporary working residents.)
Format is     854- 46- 7896

Primary Care Physician (PCP):
PCP is the provider who provides initial care and refers the patient to the other provider for special services.
BLOCK NO WHERE IT IS MENTIONED IN CMS 1500    -    BLOCK NO 17

National Provider Identification number (NPI):
It is a 10 digit number given for every US provider by US government.
RENDERING PROVIDER NPI NUMBER IN CMS 1500   - BLOCK NO 24J
REFERRING PROVIDER OR PCP NPI NUMBER IN CMS 1500-   BLOCK NO 17B

TAX ID:
Tax payer identification number (TIN). It is a 9 digit unique number given for every provider by US government.
TAX ID NUMBER IN CMS 1500 FORM -   BLOCK NO 25

Billed AMOUNT(OR)CHARGED AMOUNT(OR)TOTAL AMOUNT
It is the total amount charged for a claim service.
BILLED AMOUNT IN CMS 1500 FORM     - BLOCK NO 28

FEE SCHEDULE:
It is the document that gives the cost for each cpt code.

ALLOWED AMOUNT:
The maximum amount fixed by the insurance company for a CPT code is based on the insurance fee schedule.

Paid Amount:
It is the amount paid to the provider by insurance.

Patient Responsibility:
It is the amount patient has to pay.
It is Co- Insurance, Co-Pay, and Deductible.
Deductible:
Patient has to satisfy certain amount which was fixed by insurance company after satisfying that amount only insurance will pay for his medical benefits.
Copay :
It is the initial amount paid to the provider before taking the service by patient
Co-Insurance:
It is patient responsibility that patient has to pay if there is no secondary insurance.


INSURANCE:-
Primary Insurance:
It is the insurance that is first responsible for making payments to the providers.
Secondary Insurance:
It is the insurance that is second responsible for making payments to the provider after the primary insurance.
Tertiary Insurance:
 It is the insurance responsible for making the payments after secondary insurance.

Co-Ordinate Benefit(COB):
Patient has to decide who is primary and who is secondary before taking policy.

Allowed Amount(AA) = Paid Amount(PA) + Patient Responsibility(PR)

Paid Amount(PA)   = Allowed Amount(AA) - Patient Responsibility(PR)

Federal Insurance Names:
MEDICARE:
It provides health care benefits for the people who are above age 65 and who are suffering from long disease and who is physically handicapped.

What are the plans involved in MEDICARE
They are four types of plan in Medicare they are
Medicare Part A: hospital coverage or it will cover inpatient
Medicare Part B:  Physician services or Outpatient
Medicare Part C: DME (Durable Medical Equipment)
Medicare Part D: Medicines

What is TFL for Medicare?
TFL for Medicare 1 year

WHAT IS MEDICARE PART-B ANNUAL DEDUCTIBLE AMOUNT?
Medicare Part B Annual Deductible amount $183.00 for 2017

Advance Beneficiary Notice?
It is a notice sent to patient by provider when they believe service will not cover by Medicare.

PTAN?
Provider Transaction Access Number (PTAN) is a number issued to providers by Medicare, after enrolling with Medicare
Medicare insurance id looks like?
It is a SSN# followed by suffix.
SSN# -   452 -30 -8619
Medicare id- 452308619A

IN WHAT CASES MEDICARE WILL PAY AS SECONDARY INSURANCE?
1. Worker Compensation
2. Auto Insurance
3. Veterans Administration insurance


MEDICAID:
 It will provide the health care benefits for the people who are below poverty line.
(OR)
It will cover health care benefits for poor people in US.

Medicaid spends down program:
If a person earnings totally spent on health care expenses. He is eligible for Medicaid spends down program.

TRICARE:-
It will provide the healthcare benefits for army people families and retired employees.
(OR)
IT WILL COVER HEATHCARE BENEFITS FOR ARMY PEOPLE IN US.

CHAMPVA:-
It will provides health care benefits for the dependents of veterans
(OR) people who are disabled in armed service.

WORK COMPENSATION:
It will provide the healthcare benefits for the employee who subjected to illness (or) accidents which happens during the work time.
(OR)
It will provide the health care benefits for the employee (who become ill or injured in worked time).

COMMERICAL INSURANCES:
Commerical Ins     PhoneNo               Corrected/Appeal Calims TFL(Days) from Denied Date
 UHC                  1 877-842-3210     90 days
 AETNA             1 800-624-0756    180 days
 CIGNA              1 800-102-4464     90 days
 HUMANA         1 800-457-4708   180 days
 QUALCHOICE                              120 days
 CARE IMPROVEMENT               120 days
 BLUE CROSS BLUE SHIELD    
 MOLINA HEALTHCARE

Place of service(POS)-
 It is the place where service is rendered.
 Office visit - 11
 In patient - 21
 Outpatient -22
 Emergency - 23
 Ambulatory services -24
 Skilled Nursing Facility- 31
 POS MENTIONED IN CMS 1500 -- Block 24B

Physical Address (OR) Facility:-
It is place where provider office or facility is located.
Facility MENTIONED IN CMS 1500 -- BLOCK NO 32

Billing Address:-
It is place where EOB and cheques are sent by insurance company .
Billing Address MENTIONED IN CMS 1500 -Block 33

Clearing House:-
It is a Middle office between provider and insurance company.

What is the clearing house you are using in previous office?
Ans: EMDEON

Rejection:
Claims will be returned from clearing office or insurance company is called rejection.

PAYMENT WILL BE MADE IN THREE WAYS:
1. CHEQUE
2. EFT (Electronic fund transfer): It is way of transferring fund electrically.
3. CREDIT CARD

Charge Sheet (OR) Super Bill (OR) Medical Records(MCR#):
Simply it is called medical records.
It contains details of provider name, Date of service, disease and service details.

Cross over claim:
When claim information is sent from a primary insurance to secondary insurance it is considered as cross over claim.
For example, claim is transferred to primary insurance Medicare and after paying the claim by Medicare. it will transfer the claim directly to secondary insurance.

HIPAA:  (Health Insurance Portability and Accountability Act)
It is Law implemented in 1996 by CMS. It is used to protect health records from third party.

Appeal:
A formal request sent to insurance company asking to reprocess the claim.
Reprocess:
If insurance denied claim incorrectly we are asking to reverify the claim to get the payment it is called Reprocess

CMS:  Centre for Medicare and Medicaid service.
HCFA: Health care financing administration. Formerly known as CMS

Assignment of Benefits(AOB):
It is a legal agreement between patient and insurance company to release funds to the provider.
AOB MENTIONED IN CMS 1500 --- BLOCK NO 13

Release of Information (ROI)- It is agreement between patient and provider to release patient health information to insurance company.
ROI MENTIONED IN CMS 1500 --- BLOCK NO 12

Claim will be sent in 3 ways
1. Electronic payer id
2. Mailing address
3. Fax#

MEDICARE INSURANCE YOU WILL TRANSFER THE CLAIMS ELECTRONICALLY OR THRU MAILING ADDRESS?
ANS:   ELECTRONICALLY

MANGED CARE PLANS:
They are four types of managed care plans they are
1 HMO (Health Maintenance Organization)
2 PPO (Preferred Provider Organization)
3 EPO (Exclusive Provider Organization)
4 POS (Point Of Service)


                                     HMO PPO EPO POS
PCP YES NO YES YES
REFERRAL YES NO YES YES
INNETWORK YES YES YES YES
OUTNETWORK NO YES NO YES
AUTHORIZATION YES YES YES YES


HMO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE HMO PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2. NEED TO VISIT IN-NETWORK PROVIDER  AND OUT-NETWORK PROVIDERS NOT ELIGIBLE
3. AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT  CLAIMS

PPO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE PPO PLAN, PCP AND REFERRAL IS NOT NEEDED .
2. IN-NETWORK AND OUT-NETWORK PROVIDERS ARE ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS

EPO PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE EPO PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2. NEED TO VISIT IN-NETWORK PROVIDERS  AND OUT-NETWORK PROVIDERS ARE NOT ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS



POS PLAN-IT IS MANAGED CARE PLAN
1. IF WE TAKE POS PLAN, PCP IS COMPULSORY AND REFERRAL IS COMPULSORY
2.  IN-NETWORK AND OUT-NETWORK PROVIDERS ARE ELIGIBLE
3.  AUTHORIZATION IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIMS

PTAN:
IT IS THE NUMBER GIVEN FOR EVERY US PROVIDER AFTER REGISTERING WITH MEDICARE INSURANE

CORRECTED CLAIM:
After making Necessary changes in claim form it is considered as CORRECTED CLAIM.

HOW YOU WILL SUBMIT CORRECTED CLAIM?
After making necessary changes I will type CORRECTED CLAIM in 19 TH BLOCK and I will submit to insurance company.

W9 Form:
W9 form is used for updating the provider billing office address and provider related information with insurance.

Date Of Birth Rule(DOB Rule):
According to date of birth rule, for a child primary and secondary insurance is selected (when mother and father is having insurance)
Mother 02/09/1992
Father 06/27/1990
In this case according to month decision is taken not year
Hence, Mother insurance is primary and father is secondary

Beneficiary (OR) Insured Person :
 A person eligible for receiving benefits under insurance policy. He is also called as subscriber.

HOSPICE:
It provides Medical care and Treatment for persons who will be dying soon.