Online Training at soundofheaven.info Aging- One of the medical billing terms referring to the unpaid insurance claims or patient balances that. Medical Billing-Simple Manual - Free download as PDF File .pdf), Text File .txt) or read online for free. eligibility and guarantees coverage without regard to pre-existing medical Most medical billing software's have the ability to generate a separate report for.
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PDF- Medical Billing. About this webmix: No description. Related keywords: Maintain Patient Interaction. Created by: Outsource Strategies In.. Webmix users: . Medical Billing Flow Chart Revenue Cycle Management System Eligibility Patient's coverage is verified prior to visit Clearing ClearingHouses Houses Coding. Which are currently using paper for documenting and/or billing Software which allows ONLY case documentation for medical or behavioral.
A bacterial infection that occurs through an accidental cut or wound of from a medical or surgical treatment of a sickness may be a covered injury. Plus Blue Shield has numerous comprehensive commercial programs known as fee-for-service programs. Incorrect or missing place of service Plans accept two digits or two letters; each plan has different preferences. Group Health Plan: Some will cover them only after a waiting period. Photocopy the policy provisions and benefits, write down phone numbers of where benefits are to be verified and if pre-authorizations are required. Certain insurance plans do not cover certain services or prescription medications.
Commercial carriers offer contracts to individuals and groups, mostly groups, under which payments are made to the beneficiary or to the providers if they have accepted assignment of benefits according to an indemnity table or schedule of benefits for medical services. Commercial plans generally do not have special contract agreements with physicians. In commercial plans it up to the patient to file their claims.
It should be noted that not every service is covered under commercial plans; each one has it own benefits and exclusions. In general, most commercial plans use UCR as a basic for maximum payment cost. Most commercial plans conform to one of three basic types:. These benefits include hospital, office, physician and lab charges.
These types of plans cover minor health problems. These policies are designed for catastrophic situations only, and there is no payment under such plans for minor health problems. They usually take up where basic plans leave off, and almost always have large deductibles and copayments. These plans consist of combinations of Basic and Major Medical benefits.
Blue Cross pertains to inpatient hospital services, nursing homes, and home health care services to their subscribers. Independent, generally non-profit community service organizations that provide prepaid health care services to their subscribers. Blue Shield. There are many different programs within the system.
Blue Shield has provisions for two types of providers:. Indemnity providers — this provider has a contract to see Blue Shield patients, the physician is not obligated to file insurance claims or write off the difference of the actual charge and the allowed charge.
The providers office may collect in full from the patient at the time service is rendered. UCR providers — this provider has a special contract with Blue Shield whereby the physician agrees to see Blue Shield patients, file insurance claims and wait for the payment before collecting from the patient.
The physician also agrees to write off the difference between the actual charge and the Blue Shield allowed charge.
This is hospital insurance including skilled nursing facilities and home health care for almost everyone over the age of 65, the permanently disabled, and those with chronic renal disease. This is known as Supplementary Insurance. The Medicare ID card determines the exact coverage of the patient. A cross-over patient, is one who has Medicare as primary coverage and Medicaid as secondary coverage due to low income status. This is health care assistance program administered jointly by the federal and state governments.
Each state sets up and operates its own program within the general guidelines set down by the federal government. This is not an insurance program. It is a state funded assistance program. Eligibility is month-to-month and based on the income of the recipient. The claim forms used must be those designated by the carrier. They must be submitted within certain dates, complete in every detail, and routed first to all other possible sources of payment.
This program that makes health care benefits available to dependents of active military personnel, as well as retired military personnel and their families.
These people can go non-military doctors for medical services and have part of the cost paid by the Federal government. This covers medical expenses and disability benefits for workers whose injuries or illnesses are the result of doing their jobs. The previous six lists deal with organizations which pay for medical services but do not provide it.
When services are rendered to the patient the patient does not pay any additional payments, co-payment or deductibles. Kaiser-Permanente is the most well known HMO of this type. This type hires physicians directly and pays them a salary instead of contracting with a medical group.
In this type of plan the physicians are not employees and are not paid salaries. They are paid fees for their services out of a fund drawn from the premiums collected by the organization that markets the health plan. An IPA makes contractual arrangements with physicians in the community who provide services from their own offices. In this type of plan the HMO contracts with two or more group practices to provide health care services to its members.
There are many forms of health insurance plans currently in effect in the United States. Some examples of these are, Blue Shield who has hundreds of plans throughout the U. Plus Blue Shield has numerous comprehensive commercial programs known as fee-for-service programs. There are Central Certification Programs that cover major corporations with employees all across America. This program allows these employees to receive benefits of the contract regardless of the state where the service is preformed.
What does this mean to you as a medical biller? Each of these policies will have different rules and regulations it is governed by, with different Exclusions and Limitations. Photocopy the policy provisions and benefits, write down phone numbers of where benefits are to be verified and if pre-authorizations are required. I know this all sounds so overwhelming right now. But by the end if this text book it will all make sense.
All these details will be presented and covered in later chapters. The contract or policy is the document that describes the plan benefits, eligibility, effective date, termination of coverage and Exclusions.
Basic health insurance coverage includes benefits for hospital, surgical and other medical expenses. These contracts or policies are designed to offset large medical expenses caused by prolonged illness or serious injury.
When a policy is issued, the applicant becomes part of the insurance contract or plan. An insurance policy is a legal document between the insured, which can be an individual person or an employer group. Each party must abide by the terms set forth in the contract. The insured receives a formal written policy from the insurance carrier in legal language that needs an attorney to interpret.
Whereas, most insurance carriers also give the insured a coverage booklet, this is especially true in the case of an employer group. The booklet is a simplified explanation or interpretation of the actual policy or contract. The booklet gives general information of the contract or policy.
Not every minuet detail or service can be predicted or written into a plan, if it were, the document would read like a never-ending soap opera! The contract or plan does give exact amounts in terms of the deductibles, coinsurance, and maximums. Asking question such as plan deductibles, maximums, percentages, and second surgical opinions. Health insurance plan provisions cover items as renewals, coordination of benefits with other carriers, assignments, plan limitations, case management, and exclusions.
Here we will go over a few of the key terms that you will see throughout this textbook, as well as hearing them constantly in the insurance industry. Assignment of Benefits: To determine where and who the payment will be sent the insurance carrier refers to Block 13 on the HCFA form. If Block 13 on the HCFA form is signed by the patient or insured if patient is a minor , this informs the insurance carrier that the patient knows the payment will be sent directly to the provider, for all the services referenced in Block 24A — 24K of the HCFA form.
Accepting Assignment Do not get this term confused with assignment of benefits. Accepting assignment for some plans carries a high degree of liability for the provider to abide by the rules set by the plan. The provider Accepting assignment entails agreeing with many special rule and regulations set by a specific plan or program.
Authorization for certain treatments or visits, a prior authorization for the service and approval for that service must be obtained from the payor. This is usually attached to a document, which is used in connection with the billing to the payor. Either a numeric entry on the HCFA claim form for electronic transmission or as a document attached to a paper claim when mailed to the insurance carrier. Pre-certification or Predetermination many private insurance carriers and prepaid health plans require one or the other, before they will approve certain hospital admissions, inpatient or outpatient surgeries and elective procedures.
The carrier can refuse to pay part or the entire fee if this requirement is not met. Pre-determination means discovering the maximum dollar amount that the carrier will pay for primary, consulting services, postoperative care, and so on.
Pre-authorization relates not only to whether a service or procedure is covered but also to finding out whether it is medically necessary. Coordination of Benefits is a process that occurs when two or more group plans provide coverage on the same person. Primary plan benefit plan determines and pays its normal benefits first without regard to the existence of anyother coverage.
Secondary Plan pays after the primary plan has paid its benefits. ICDCM codes are 3,4 or 5-digit numerical codes from The three-digit code is the parent code giving the name of the disease. The supplemental four or five digit codes under that three-digit code are more specific. We should use the three-digit code only where the fourth or fifth digit is not available. In addition there are V-codes and E-codes. This is a Five digit numeric code starting from They are alphanumeric codes, which are accepted by certain limited carriers and are used in cases where no appropriate code figures in CPT ASA Codes developed by the American Society of Anesthesiologists are codes that need to be used for anesthesia billing.
The code range from through All Medicare carriers and certain Medicaid carriers accept these codes. A modifier provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance.
Modifiers may be used to indicate to the recipient of a report that: Place of service Place of Service denoted the place where the service was rendered within the facility. For e. Certain carriers adopt the Medicare coding for Place of Service while certain other have their own coding systems. Medicare places of service for inpatient is 21, outpatient is 22, office consultation is 11, emergency room is 23, ambulatory surgical center is 24 and so on.
Type of Service Type of Service is the specialty in which the service is rendered. Provider enrollment is the crux of a proper billing set up. Before we send claims to insurance companies, we should ensure that all provider doctors are enrolled with the respective carriers, all providers are contracted. For Federal carriers such as Medicare and Medicaid, we need the provider to submit the claims. Otherwise they would get denied. In order to get this; we need to act at the inception itself.
When a new provider has joined the group, we need to ensure the following: Without the State License the doctor cannot perform in that State. If so we can just write a letter to the carrier saying that this provider has joined the group and request them to merge the provider with the group.
Where the provider does not have a contract with a carrier, a fresh application for enrollment is required. A Fresh application in Form is filled and signed by the doctor and sent to the carrier. The carrier processes it and sends in intimation mentioning the provider. Box 33 of the also contains the Pay-to address where the checks and EOBs need to be sent by the carriers. But Medicare and Medicaid do not go by what is mentioned in the box with regard to pay-to address.
Based on the pay-to address mentioned in Form at the time of enrollment the carrier records it in its system. All checks and EOBs will be sent to this address. If there is a change of address , the carriers need to be notified in Form C. Based on this , the carriers update this information in their system. Certain carriers have the facility to accept claims electronically. For this purpose we need to enroll the providers with the EDI Department of the insurance carriers.
This is mandatory requirement in the case of Federal Carriers such as Medicare and Medicaid. This is a separate process apart from the above Provider Enrollment process.
We need to fill in a separate EDI enrollment form for providers and send them to the carrier. The carrier will then add the provider in the EDI database. Only then can we submit claims to that carrier for that provider electronically.
Definitions of Insurance Terms The following are general definitions of some common insurance terms related to insurance companies and medical insurance policies. A claim is a request for payment from your insurance company for medical expenses incurred due to an illness or injury covered under the terms of the policy. Each company has requirements for how a claim is to be made; what forms must be completed by you and your doctor s ; and what additional information, forms, or reports are required before payment can be made.
One of the biggest problems with claims made by students is that forms are not completely filled out. This means the insurance companies or claim administrators cannot pay the claim.
Some insurance companies require you provide the original bill s along with the claim form. You should keep photocopies of all the documents you submit for a claim.
Covered Injury: This is an injury that occurs while your insurance policy is in force and for which you have received medical services, supplies or treatment after the accident. A bacterial infection that occurs through an accidental cut or wound of from a medical or surgical treatment of a sickness may be a covered injury.
Covered Sickness: This is a sickness which is first diagnosed or treated while your insurance policy is in force. The co-insurance clause requires you to pay a percentage or a fixed dollar amount of your covered medical expenses. This is the amount you pay before the insurance company pays anything.
There are two types of deductibles: Under an annual deductible, you will pay all expenses up to the amount of the deductible. Once you have paid the deductible during the policy year, the insurance company will pay for covered medical expenses for the rest of the policy year in accordance with the terms of the policy. Under a per occurrence deductible, you must pay the deductible amount for each separate sickness or injury.
If you have five claims in one year, you would have to pay the deductible five times. Example 1: Example 2: The insurance company will pay its share of any additional expense. These state the types of injuries or illnesses that are not covered.
All policies have exclusions. The most common types of exclusions are pre-existing conditions, self-inflicted injuries, and injuries incurred while committing a criminal act. Injuries resulting from some specific activities may also be excluded. For example, if you plan to drive a car or snow ski, these activities may be excluded. Never assume you will always be covered. Check the exclusions before you purchase insurance.
Under this alternate type of health care, you receive all medical services from the HMO for a pre-determined fee. If you do not use the medical services from the HMO to which you belong, you will have to pay for your medical care. If the HMO ceases to operate, you will also have to pay for your own medical care. If you receive medical care at a hospital or clinic for at least one full day and are charged room and board, you are an inpatient. All insurance policies in the USA have stated limits for the medical benefits they will pay.
They also have maximum limits for what will be paid for certain services. For example, the policy may state limits to what it will pay for a daily hospital room, surgical or physician fees. Medical Evacuation and Repatriation: Evacuation means the company will pay the cost of transporting you to a special medical facility or to your home because of a covered medical condition.
Repatriation means the insurance company will pay transportation costs to return your remains home if you die while in the USA.
Necessary Treatment: This is medical or dental treatment that is a consistent with generally accepted medical practice for the covered injury or covered sickness; b in accordance with "approved" and generally accepted medical, surgical or dental practice as determined by the insurance company; c accepted as safe, effective and reliable by a medical specialty or board recognized by the American Board of Medical Specialties; and d not "experimental or investigational" treatment as determined by the insurance company.
If you receive medical treatment from a physician or in a hospital or clinic, but are not confined or charged room or board, you are an outpatient. Pre-existing Conditions: This refers to any medical conditions that existed before your policy goes into effect. If you are to arrive in the USA on August 1 and your policy goes into effect that day, any medical condition that existed before August 1 would not be covered. Some policies have a waiting period such as 6 months after which pre-existing conditions may be covered.
This is a network of physicians, hospitals and clinics that provide services for pre-negotiated fees. The insurance company will pay a greater portion of your medical expenses if you go to the PPO. This is the amount of money you will be required to pay for your insurance coverage.
It is generally expressed in monthly terms. You will pay the monthly premium in US dollars for each month of coverage you purchase. If the premium is not paid, the policy will not be in force.
Reasonable Expense: This is the reasonable and customary fee or charge for services, supplies and treatment in the area in which they are received. A participating provider has signed a participation agreement with Medicare to submit only assigned claims and follow all the regulations for assigned claims.
The provider has agreed to accept as payment the Medicare allowed amount for a given service.
A nonparticipating provider has not signed a participation agreement with Medicare and can submit either assigned or nonassigned claims. This can be done on a claim-by-claim basis.
A nonparticipating provider must follow all the regulations that apply to the type of claim submitted. Yes, unless you or your spouse are working. If you or your spouse are still working in a company with 20 or more employees, the employer group health plan would be the primary insurer. Medicare is also primary if you are disabled. If you are disabled and under 65 years of age, and you or your spouse are currently employed by a company with or more employees, Medicare is secondary to the employer group health plan.
Medicare is secondary in the following situations: The following is a partial list of services that Medicare Part B covers based on medical necessity: Ambulance transportation limited benefit Artificial limbs and eyes Bone mass measurements Breast prostheses following a mastectomy Colorectal cancer screening Diabetes monitoring Durable medical equipment Flu, pneumonia and hepatitis B immunizations Mammogram screening Mental health services Occupational therapy Outpatient hospital services Pap smear and pelvic examination Physical therapy Physician services Prostate cancer screening X-rays and laboratory tests.
The following is a partial list of services that Medicare Part B does not cover: Acupuncture Cosmetic surgery Most dental care and dentures we do not cover any dental services related to the care, treatment, filling, removal or replacement of teeth, or of structures that directly support the teeth Eyeglasses except following cataract surgery with an intraocular lens Health care while traveling outside of the United States Hearing aids Orthopedic shoes Prescription drugs Routine eye care Routine foot care in most cases Routine or yearly physical exams.
A method of paying medical providers through a pre-paid, flat monthly fee for each covered person. The payment is independent of the number of services received or the costs incurred by a provider in furnishing those services.
The Consolidated Omnibus Budget Reconciliation Act of , commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for you and your dependents for 18 months after you leave your job. Longer durations of continuance are available under certain circumstances. If you opt to continue coverage, you must pay the entire premium, plus a two percent administration charge.
A payment system for health care where the provider is paid for each service rendered. You must choose a primary care physician who coordina tes all of your care and makes referrals to any specialists you might need.
Lifetime Limit: A cap on the benefits paid under a policy. These health insurance plans provide incentives for individuals to replace high premium, low-deductible policies with affordable, high deductible catastrophic coverage. Premiums for this coverage are lower and the savings may be used to fund a tax-pre ferred medical savings account from which you can pay on a pre-tax basis for qualified medical care and expenses, including annual deductibles and copayments.
Out of-Pocket Maximum: The most money you will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service. Pre-existing Condition: A health problem that existed before the date your insurance became effective. Many insurance plans will not cover preexisting conditions. Some will cover them only after a waiting period.
Primary Care Physician: This is often a family physician, internist, or pediatrician. A primary care physician monitors your health, treats most health p roblems, and refers you to specialists if necessary.
Any person doctor or nurse or institution hospital, clinic, or laboratory that provides medical care.
In the case of high-volume third-party payers, like Medicare or Medicaid , billers can submit the claim directly to the payer. If, however, a biller is not submitting a claim directly to these large payers, they will most likely go through a clearinghouse. A clearinghouse is a third-party organization or company that receives and reformats claims from billers and then transmits them to payers.
Some payers require claims to be submitted in very specific forms. Clearinghouses ease the burden of medical billers by taking the information necessary to create a claim and then placing it in the appropriate form.
Think of it this way: A practice may send out ten claims to ten different insurance payers, each with their own set of guidelines for claim submission. Instead of having to format each claim specifically, a biller can simply send the relevant information to a clearinghouse, which will then handle the burden of reformatting those ten different claims.
Once a claim reaches a payer, it undergoes a process called adjudication. A quick word about these terms. An accepted claim is, obviously, one that has been found valid by the payer.
Accepted does not necessarily mean that the payer will pay the entirety of the bill.
Rather, they will process the claim within the rules of the arrangement they have with their subscriber the patient. A rejected claim is one that the payer has found some error with. In the case of rejected claims, the biller may correct the claim and resubmit it. A denied claim is one that the payer refuses to process payment for the medical services rendered. This might include a procedure for a pre-existing condition if the insurance plan does not cover such a procedure.
This report will list the procedures the payer will cover and the amount payer has assigned for each procedure. This often differs from the fees listed in the initial claim. The payer usually has a contract with the provider that stipulates the fees and reimbursement rates for a number of procedures. The report will also provide explanations as to why certain procedures will not be covered by the payer. The biller reviews this report in order to make sure all procedures listed on the initial claim are accounted for in the report.
Finally, the biller will check to make sure the fees in the report are accurate with regard to the contract between the payer and the provider.
This process is complicated and depends on rules that are specific to payers and to the states in which a provider is located. Effectively, a claims appeal is the process by which a provider attempts to secure the proper reimbursement for their services. The statement is the bill for the procedure or procedures the patient received from the provider. Once the payer has agreed to pay the provider for a portion of the services on the claim, the remaining amount is passed to the patient.
An EOB describes what benefits, and therefore what kind of coverage, a patient receives under their plan. EOBs can be useful in explaining to patients why certain procedures were covered while others were not.