Basic Medical Billing and Imp Questions.
Basic Medical Billing and Imp Questions.
Basic Medical Billing and Imp Questions.
It is the process of sending the Claim forms (CMS 1500 foam) to the Insurance company
on behalf of the provider office.
The statement of response which we received from the insurance company after submit
a claim .
DENIAL
It is a statement received from insurance company stating that they are not going to pay
the claim and the statement is called denial.
OR
The treatment done by the provider to the patient is converted in to alpha numeric
code is called “CPTCODE” .
Range is 5 digits.
( OR )
The disease or illness of the patient is converted in to alpha numeric code is called
“DIAGNOSIS CODE ” it’s range is 7 digit.
( OR )
REFERENCE BOOK
• Patient
• Registration
• Encounter (Facing)
• Coding
• Payment Posting/Correspondence
• Account Receivables
• Collections
MODIFIER
It is alpha numeric code that gives extra meaning to the cpt code.
What are the modifiers you used in your previous office or tell me some modifiers
what you know ?
PCP is the provider who provides initial care and refer the patient to the other provider
for special services.
TAX ID
Tax payer identification number (TIN) It is a 9 digit unique number given for every
provider by US government.
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
Patient Responsibility
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 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.
,Teritiary Insurance
It is the insurance responsible for making the payments after secondary insurance.
Co ordinate Benefit
Patient has to decide who is primary and who is secondary before taking policy .
Medicare
It provides health care benefits for the people who are above age 65, who is physically
handicapped people and who is suffering from (ESRD) End Stage Renal Disease.
The automatic transfer of a claim from primary medicare to the patient’s secondary
payer is known as medicare crossover (or) piggyback claims.
Medigap Policy
It is Medicare program offered to retired railway employees (who are above 65).
Previously It Is a SSN# followed by suffix and now it is changed to Alpha numeric code.
1 Worker Compensation
2. Auto Insurance
Medicaid
It will provides the health care benefits for the people who are below poverty line ,
pregnant women , people with disability.
Medicaid spend down program (Or) Medicaid spend down cost (SDC)
If a person earnings totally spent on health care expenses he is eligible for medicaid
spend down program.
Tricare
It will provides the health care benefits for Uniformed people and their families and
retired employees.
OR
It is a regionally managed healthcare program for active duty & retired members of the
uniformed services and there families.
Champva
It will provides health care benefits for the spouse or child of a veteran who has been
rated permanently and totally disabled for a service connected disability.
Work Compensation
It will provide the health care 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)
It is a notice sent to patient by provider when they believe this service will not cover by
Medicare.
PTAN
Commercial Insurance
• UHC 1 877-842-3210
• AETNA 1 800-624-0756
• CIGNA 1 800-102-4464
• HUMANA 1 800-457-4708
• QUALCHOICE
• CARE IMPROVEMENT
Place of service
Office visit - 11
In patient - 21
Out patient -22
Emergency - 23
insurance company .
Clearing House
GATEWAY
Rejection claims will be returned from Clearing office or insurance company is called
rejection.
1 CHEQUE
It is Law implemented in 1996 by CMS. It is used to protects health records from third
party.
Appeal
Reprocess
If insurance denied claim incorrectly we are asking to reverify the claim to get the
payment it is called Reprocess
CMS
HCFA
1.Electronic payor id
2.mailing address
3.fax#
ANS : ELECTRONICALLY
MANAGED CARE PLANS:
• Managed care plans are mainly introduced to give better health benefits plan at
affordable price and also to avoid patient’s misuse of the policy.
• Co-pay was introduced in managed care plan .
• Network and PCP concept applicable.
• Preventative service are covered.
• Authorization concept has been introduced.
• Premium is less compared to indemnity/traditional plan.
PPO PLAN
EPO PLAN
POS PLAN
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
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
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.
AGING
Aging report is useful for catching charges that are going unpaid. It has breakdown of
aging bucket and it is calculated from dos.
30 FRESH CLAIM
30-60 1 ST FOLLOWUP
120+ FOLLOWUP