Professional Documents
Culture Documents
PROCESS MANUAL
high level of technology available in the U.S. contributes to quality care, and the
Medical and health care is big business. Hospitals and medical schools also spend
will bring them prestige, patients, and money, while benefiting many people. The
result for consumers is ever improving quality and effectiveness of medical care,
When seeking any kind of medical assistance in the United States, there are few
free services, and most care is expensive. Unlike other countries, there is little
government sponsored health care here, except for those over 65 years of age
(Medicare), or for the poor (Medicaid). The insurance industry is a major influence
in the business of staying well or regaining one's good health. Obtaining some
type of health insurance coverage to protect one self and their family is very
911 first. In such situations, time is the most important factor in preventing
damage or even loss of life. The operator handling your "911" call will immediately
routing individual’s call to a counselor who will guide through the situation until
paramedics, are highly trained in dealing with trauma and making split-second
individual will begin to receive treatment immediately and will be taken to the
facility that can best handle the situation, whether it is a trauma center, a burn
or a friend with the individual, they will be asked for the name of patient’s doctor,
it is also expensive. There will be a fee for the ambulance, the emergency room,
any medications administered, the services of doctors involved and any tests or
genuine emergency but these services are not intended for situations where a call
An additional note about "911" This number is also used in police emergencies,
have health insurance coverage, he / she have to pay for health care out of their
own finances at the time of service. This can run into many thousands of dollars
their family are protected in case of any medical care that could be very
expensive.
One cannot predict what his medical bills would be. In a good year, costs may be
low but if he becomes ill, medical bills could be very high. If he has insurance,
many of medical costs are covered by a third-party payer, not by the individual. A
employer.
Many people in the United States are enrolled in some sort of managed care plan.
This is an organized way of both providing services and paying for them. Different
types of managed care plans work differently and include preferred provider
insurance for the time when they will need medical attention. At the time when a
service is provided, the health insurance organization pays part or the entire fee,
Choosing the right insurance plan that best meets financial circumstances will
children or no children. Definitions of the health insurance terms used are included
The two main ways that people obtain health coverage are by paying into a group
Most Americans get health insurance through their jobs or are covered because a
family member has insurance at work. This is called group insurance. Group
insurance is generally the least expensive kind. In many cases, the employer pays
Some employers offer only one health insurance plan. Some offer a choice of plans
Provider Organization (PPO), for example. Employers with 25 or more workers are
keep the same policy, but he will have to pay for it himself. This will certainly cost
him more than group coverage for the same, or less, protection. A Federal law
makes it possible for most people to continue their group health coverage for a
period of time called COBRA (for the Consolidated Omnibus Budget Reconciliation
Act of 1985), the law requires that if an individual work’s for a business of 20 or
more employees and leave the job or are laid off, he can continue to get health
he was working.
He / she also will be eligible to get insurance under COBRA if their spouse was
under his parents group plan while he was in school, he can also continue in the
plan for up to 18 months under COBRA until the individual find a job that offers
Not all employers offer health insurance. Individual might find this to be the case
with his job, especially if he work’s for a small business or work part-time. If the
employer does not offer health insurance, he might be able to get group insurance
organization.
buy an individual policy. One can get fee-for-service, HMO, or PPO protection. But
an individual should compare the options and shop carefully because coverage and
costs vary from company to company. Individual plans may not offer benefits as
You will hear the term "managed care" quite a lot in the
costs. Managed care influences how much health care an individual use. Almost all
plans have some sort of managed care program to help control costs. For
admitted to make sure that the hospitalization is needed. If he goes to the hospital
without this approval, he may not be covered for the hospital bill.
Fee-for-Service Plans
This is the traditional kind of health care policy. Insurance companies pay fees for
the services provided to the insured people covered by the policy. This type of
health insurance offers the most choices of doctors and hospitals. An individual
can choose any doctor he wishes and change doctors any time. He can go to any
With fee-for-service, the insurer only pays for part of doctor and hospital bills.
A certain amount of money each year, known as the deductible, is paid for by the
individual before the insurance payments begin. In a typical plan, the deductible
might be $250 for each person in a family, with a family deductible of $500 when
at least two people in the family have reached the individual deductible. The
deductible requirement applies each year of the policy. Also, not all health
Individuals need to check the insurance policy to find out which ones are covered.
After individual has paid deductible amount for the year, he would share the bill
with the insurance company. For example, individual might pay 20 percent while
To receive payment for fee-for-service claims, individual may have to fill out forms
and send them to insurer. Sometimes doctor's office will do this for Insured.
Individual also need to keep receipts for drugs and other medical costs and is
There are limits as to how much an insurance company will pay for a claim if both
individual and his spouse file for it under two different group insurance plans. A
coordination of benefit clause usually limits benefits under two plans to no more
Most fee-for-service plans have a "cap," the most individual will have to pay for
medical bills in any one year. He reaches the cap when out-of-pocket expenses
$1,000 or as high as $5,000. The insurance company then pays the full amount in
excess of the cap for the items listed in policy. The cap does not include what
Some services are limited or not covered at all. Insured need to check on
protection pays toward the costs of a hospital room and care while patient is in the
hospital. It covers some hospital services and supplies, such as x-rays and
prescribed medicine. Basic coverage also pays toward the cost of surgery, whether
it is performed in or out of the hospital, and for some doctor visits. Major medical
insurance takes over where insured basic coverage leaves off. It covers the cost of
Some policies combine basic and major medical coverage into one plan. This is
The HMO arranges for this care either directly in its own group practice and/or
through doctors and other health care professionals under contract. Usually,
patient choices of doctors and hospitals are limited to those that have agreements
with the HMO to provide care. However, exceptions are made in emergencies or
visit or $25 for hospital emergency room treatment. Individual total medical costs
will likely be lower and more predictable in an HMO than with fee-for-service
insurance.
Because HMOs receive a fixed fee for your covered medical care, it is in their
interest to make sure patient get basic health care for problems before they
become serious. HMOs typically provide preventive care, such as office visits,
Some services, such as outpatient mental health care, often are provided only on
a limited basis.
Many people like HMOs because they do not require claim forms for office visits or
hospital stays. Instead, members present a card, like a credit card, at the doctor's
office or hospital. However, in an HMO individual may have to wait longer for an
In some HMOs, doctors are salaried and they all have offices in an HMO building at
practice. In others, independent groups of doctors contract with the HMO to take
care of patients. These are called individual practice associations (IPAs) and they
are made up of private physicians in private offices who agree to care for HMO
as patient’s primary care doctor. This doctor monitors health and provides most of
patient’s medical care, referring to specialists and other health care professionals
as needed. Patient usually cannot see a specialist without a referral from primary
care doctor who is expected to manage the care received by the patient. This is
between the insurance and the provider. In brief let us see what it is.
Capitation
Many HMO plans and some PPO plans are considering capitated. When a plan is
capitated the doctor and treatment center receives a monthly payment from
insurance company based on the number of enrollees. The monthly payment may
be varying due to increase or decrease and the treatment centers are paid more
charge entry process, but none of the claims are mailed. This is because under a
capitated plan, since the doctors and treatment centers are paid monthly
regardless if they treat a patient. When they do treat a patient. They can not bill
the insurance company for the services rendered. If a claim is accidentally issued
to the insurance company, they automatically deny the claim as a provider with a
capitated plan, and you hope that none of the enrollees ever became patients
Many HMOs offer an indemnity-type option known as a POS plan. The primary
care doctors in a POS plan usually make referrals to other providers in the plan.
But in a POS plan, members can refer themselves outside the plan and still get
some coverage.
If the doctor makes a referral out of the network, the plan pays all or most of the
bill. If patient refer themselves to a provider outside the network and the service
and an HMO. Like an HMO, there are a limited number of doctors and hospitals to
choose from. When patient use those providers (sometimes called "preferred"
small co-payment for each visit. For some services, patient may have to pay a
As with an HMO, a PPO requires that patient choose a primary care doctor to
monitor his health care. Most PPOs cover preventive care. This usually includes
some coverage. At these times, patient will pay a larger portion of the bill himself
(and also fill out the claims forms). Some people like this option because even if
their doctor is not a part of the network, it means they do not have to change
preferred provider organizations (PPO). Each plan has its own features to consider
FFS advantages:
FFS disadvantages:
insurance company starts paying claims, and then doctors are reimbursed
about 80 percent of the bill while patient pick up the remaining 20 percent.
patient’s doctor charges more than the average for the area, patient will
HMO
HMOs are the least expensive, but also the least flexible of all the health insurance
plans. They are geared more toward members of a group seeking health
insurance.
HMO advantages:
HMO disadvantages:
• HMOs require that individual see only network doctors or they won't pay.
POS
POS plans are more flexible than HMOs, but they also require patient to select a
PCP.
doctor outside the network and still receive coverage — but the amount
the network.
• These plans tend to offer more preventive care and well-being services,
POS disadvantages:
if any.
PPO
PPO advantages:
• The standard co-payment is $10 for a routine office visit during regular
hours.
network, or pay the difference between what network doctors vs. out-of-
Types of Insurance
MEDICARE
Medicare is the federal (national) health insurance program for Americans age 65
Medicare has two parts hospital insurance, known as Part A, and supplementary
medical insurance, known as Part B, which provides payments for doctors and
related services and supplies ordered by the doctor. If individual is eligible for
Medicare, Part A is free, but insured must pay a premium for Part B.
Medicare will pay for many of insured health care expenses, but not all of them. In
particular, Medicare does not cover most nursing home care, long-term care
services in the home, or prescription drugs. There are also special rules on when
Medicare pays patient’s bills that apply if patient have employer group health
Some people who are covered by Medicare buy private insurance, called
"Medigap" policies, to pay the medical bills that Medicare doesn't cover. Some
Medigap policies cover Medicare's deductibles; most pay the coinsurance amount.
Some also pay for health services not covered by Medicare. There are 10 standard
plans from which individual can choose (some States may have fewer than 10.) If
an individual buy a Medigap policy, he should make sure that he does not
MEDICARE PART A
determines payment to Part A facilities for covered items and services provided by
• Hospice Care.
The services and coverage limitations for each of Medicare Part A Care:
• Blood transfusions
• Lab tests
the Hospital.
Benefit period begins when the first day (not on the previous benefit period) on
consecutive days (after the date of discharge from the facility) during which the
patient was neither an inpatient hospital nor a Skilled Nursing Facility (SNF).
medical necessity for the admission and the number of days has been proven. The
patient also has a lifetime reserve of 60 days, which could be used once the 90
days have been exhausted. Once the reserve days have been used, they are not
replenished.
Part A services and coverage for Inpatient Care in a Skilled Nursing Facility (SNF):
• Semi-private room
• Any services not provided by the facility and included in its bill.
Duration of Care:
Benefit period – A benefit period begins with the first day (not in a previous
extended care services by a qualified provider. The benefit period ends with the
close of a period of 60 consecutive days (after the date of discharge from the
facility) during which the patient was neither an inpatient of a hospital nor an
Eligible benefits – A patient is eligible for 100 days of care in a SNF during a
benefit period, as long as medical necessity for the admission and the number of
Part A services and coverage for Inpatient Care in a Home Health Care:
• Part-time or intermittent skilled nursing care and home health aid services
• Physical therapy
• Occupational therapy
• Medical supplies
Non-covered Medicare Part A Home Health Care services include the following:
• Homemaker services
• Blood transfusion.
Duration of Care:
Eligibility requirements – The eligibility requirements for home health services are:
pathology services
certification that is part of the plan of care and the agency must meet
program.
• Nursing services
• Doctors services
• Drugs, including outpatient drugs for pain relief and symptom management
• Counseling
terminal illness
• Regular Medicare can usually help pay for treatment not related to the
terminal illness.
of six months or less who elect to forego traditional medical treatment for the
election periods of hospice care. The periods consist of two 90-day periods, one
MEDICARE PART B
part B typically thought of as insurance for physician services (in both hospital &
physician services
• Physician Services
• Non-Physician Services
• Diagnostic Tests
• Ambulance Transportation
function.
above definition are subject to any limitations imposed by CMS 1500, the state
licensing agency or the local Medicare contractor on the scope of practice. If any
limitations are placed on the scope of practice, Medicare will only cover items or
services within the limitation. For example, Medicare limits reimbursement for
Covered Medicare Part B physician services include, but are not limited to, the
following:
covered under Medicare Part B include, but are not limited to the following:
• Medical devices or biologicals which have not been approved by the food
NON-PHYSICIAN SERVICES
therapists
Scope of Non-Physician services – The services performed by the above listed non-
physicians are subject to any limitations imposed by CMS 1500, the state licensing
agency or the local Medicare contractor on the scope of practice. If any limitations
are placed on the scope of practice, Medicare will only cover items or services
within the limitation. For example, Medicare limits reimbursement for clinical
illness, as long as coverage requirements are met – based on the scope and
following:
• X-rays
• Anesthesia
covered under Medicare Part B include, but are not limited to the following:
• Medical devices or biologicals which have not been approved by the Food
Note: All service(s) which are related to a non-covered item or service is /are also
• Acupuncture
• Hearing aids
Note: The local Medicare contractor has the ability and authority to designate an
complete list of all non-covered items or services for your state, you should
Diagnostic Procedures
outpatient x-ray and testing facilities and inpatient hospitals (interpretation only).
Keep in mind Diagnostic tests, as with all other services your provide must meet
the regular coverage requirements in order for Medicare to make payment. They
are the item or service must be reasonable and necessary for the diagnosis or
diagnoses for which payment will only be allowed. If a claim for a diagnostic test
is received and the indicated diagnosis is not on the list of covered diagnosis
codes, then Medicare will deny the service as not being medically reasonable and
Diagnostic Tests
Covered diagnostic tests include, but are not limited to the following:
• Cat scans
• Nuclear medicine
• Drug screens
• Immunology
• Transfusion medicine
• Wheelchairs
• Commode chairs
• Oxygen equipment
• Walkers
• Hospital beds
• Canes
• Nebulizers
Duration of care:
Claims for DME are processed by regional contractors (DMERC). You should
contact your local DMERC for further information regarding duration of care.
Ambulance Transportation
requirements must be met. These coverage requirements include, but are not
meet medical necessity, the patient’s condition must be such that use of any other
no Medicare payment may be made for the ambulance service. To meet the
The diagnosis requirement still needs to be met, even though the patient’s
Duration of care:
MEDICARE PART C
• Preventive Care
• Prescription Drugs
• Eyeglasses
• Dental Care
• Hearing Aids
Hospice is a special way of caring for people who are terminally ill, and for their
family. This care includes physical care and counseling. Hospice care is given by a
public agency or private company approved by Medicare. It is for all age groups,
including children, adults, and the elderly during their final stages of life. The goal
of hospice is to care for the patient and their family, and not to cure the patient
illness.
If a patient qualifies for hospice care, he/she gets medical and support services,
including nursing care, medical social services, doctor services, counseling, &
homemaker services. In many cases, the patient and their family can stay
together in the comfort of their home. Depending on the patient’s condition, they
• Patients doctor and the hospice medical director certify that a patient is
terminally ill and probably have less than six months to live;
Patient’s doctor and the hospice will work with the patient and their family to set
For a hospice patient, there is a team of people that will help take care of the
• Patient’s family
• A doctor
• A nurse
• A social worker
• Trained volunteers
Volunteers are trained to help with every day tasks, such as shopping and
personal care services, like bathing and dressing. Speech, physical, and
occupational therapists and other persons who are trained to give care are also
A Family member or other person who cares for the patient will be there every day
and members of the hospice team will make regular visits. A nurse and a doctor
are on-call 24 hours a day, 7 days a week to give the patient and their family the
Even though a doctor is a part of the hospice team, patient can choose to use
his/her regular doctor, who is not a part of the hospice to get care. The hospice
will work closely with the patient’s regular doctor to give the care that a patient
needs.
Medicare covers these hospice services and pays nearly all of their costs:
• Doctor services
• Nursing care
• Speech therapy
• Counseling to help you and your family with grief and loss
The patient, only have to pay part of the cost for outpatient drugs and inpatient
respite cares.
Respite care is care given to a hospice patient by another caregiver so that the
usual caregiver can rest. As a hospice patient, you may have one person that
takes care of you every day. That person might be a family member. Sometimes
they need someone to take care of you for a short time while they do other things
that need to be done. During a period of respite care, you will be cared for in a
The care that you get for your terminal illness must be from a hospice. When you
As a hospice patient, you can get comfort care to help you cope with your illness
not cure it. Comfort care includes drugs for symptom control and pain relief, pain
relief, physical care, and counseling and other hospice services. Hospice uses
possible. Medicare will not pay for treatment to cure your illness. You should talk
potential treatment to cure your illness. As a hospice care and go back to your
• Care from another hospice that was not set up by your hospice.
You must get hospice care from the hospice provider you chose. You can get
hospice care from another hospice provider, unless you change your hospice
provider.
• Care from another provider that is the same care that you must get from
your hospice.
Your hospice team must give all care that you get for your terminal illness. You
cannot get the same type of care from a different provider unless you change your
hospice provider.
Medicare pays the hospice for your hospice care. You will have to pay:
No more that $5 for each prescription drug and other similar products”
The hospice can charge up to $5 for each prescription for outpatient drugs or other
5% of the Medicare payment amount for inpatient respite care For example, if
Medicare pays $100 per day for inpatient respite care, you will pay $5 per day.
You can stay in a Medicare – approved hospital or nursing home up to 5 days each
respite care The amount you pay for respite care can change each year.
Yes. You should use your Medicare health plan (like the Original Medicare Plan or a
Medicare managed care plan) to get care for any health problems that are not
related to your terminal illness. You may be able to get this care from your own
doctor who is not a part of the hospice, or from the hospice doctor. When you use
your Medicare health plan, you must pay the deductible and coinsurance amounts
(if you have the Original Medicare Plan), or the copayment (if you have a Medicare
If you are in the Original Medicare Plan, you may have a medicare Supplemental
Insurance or “Medigap” policy. Your Medigap policy still helps to cover the costs
for the care of health problems that are not related to your terminal illness.
You can get hospice care as long as your doctor certifies that you are terminally ill
and probably have less than six months to live. Even if you live longer than six
months, you can get hospice care as long as your doctor recertifies that you are
terminally ill.
Hospice care is given in periods of care. As a hospice patient, you can get hospice
care for two 90-day periods followed by an unlimited number of 60-day periods. At
in order for you to continue getting hospice care. A period of care starts the day
you begin to get hospice care. It ends when your 90 or 60-day period is up. If
your doctor re-certifies that you are terminally ill, your care continues through
Sometimes a terminally ill patient’s health improves or their illness goes into
remission. If that happens, your doctor may feel that you no longer need hospice
care and will not re-certify you at that time. Also, as a hospice patient you always
have the right to stop getting hospice care, for whatever reason. If you stop your
hospice care, you will get your health care from your Medicare health plan, (like
the Original Medicare Plan or a Medicare managed care plan). If you are eligible,
you can go back to hospice care at any time. As a hospice patient, you always
have the right to stop getting hospice care and go back to your regular doctor or
health plan.
The Medicaid Program provides medical assistance for certain individuals and
individuals who fall into specific categories. Although the Federal government
Medicaid eligibility is limited to individuals who fall into specified categories. The
federal statute identifies over 25 different eligibility categories for which federal
funds are available. These categories can be classified in to five broad coverage
groups:
• Children;
• Pregnant Women;
Blue Cross plans were founded originally to cover hospital expenses. Blue shield
areas, Blue cross and blue shield plans are a single corporation. In other areas,
they are separate organizations and in some case even compete with each other.
A person becomes a member by entering into a contract with the local Blue cross
and/or Blue shield plan and by paying regular dues. The person becomes a
subscriber not a policyholder and retains a certificate not a policy, that tells him
what to expect from the contract when medical services are required.
When the BCBS plans serve as a Medicare contractor (Medicare HMO), the Blue
Cross staff within the plan handle Medicare Part A as the fiscal intermediary and
the Blue shield staff within the plan handle Medicare Part B as the carrier.
There are two basic types of blue cross and blue shield contracts: -
• Service Benefit Contracts - Offered by all BCBS plans that offer physician
themselves, rather than reimbursing the subscriber for some or all of the
subscribers.
providing covered services but not more than the actual charges for a
the full fee. A professional provider may bill the subscriber an amount in
excess of the Plan’s benefit allowance. The subscriber is responsible for any
difference between the plan’s allowance and the professional provider’s bill.
TRICARE (CHAMPUS)
Tricare is the Managed healthcare program for Active Duty service members and
Tricare formerly CHAMPUS is the Managed care program for DoD beneficiaries.
Through the 3 tricare programs Standard, Extra and Prime, Military Treatment
Facilities MTF and Civilian providers work as partners to help control the overall
The TRICARE programs are available to family members of active duty military
service members and also to military retirees and their dependents. These
dependents include spouses, unmarried children under age 21, unmarried children
who are full-time students under age 23 and stepchildren adopted by the sponsor.
Those who are eligible must be listed in the Defense Department's worldwide,
• People age 65 or older who are eligible for Medicare (with some exceptions)
• People who are eligible for health benefits under CHAMPVA (Civilian Health
database that lists everyone who is eligible for TRICARE benefits. Make sure your
DEERS record is up-to-date. This will help us process your claims quickly and
accurately.
RAILROAD MEDICARE
families under the Railroad Retirement Act and the Railroad Unemployment
Insurance Act. These programs provide income protection during old age and in
Railroad Retirement Board also administers aspects of the Medicare program and
has administrative responsibilities under the Social Security Act and the Internal
Revenue Code.
Medicare - Blue Cross and Blue Shield Plans have served as partners to the
1966. Blue Plans helped design the original infrastructure for tracking and
processing Medicare payments. Today, the Blue System collectively is the largest
that has offices, plans and people in several states and whose employees travel a
subscriber’s card indicates this is a National account. Claims are filed and paid by
illness or injury and cannot work. This is an important type of coverage for
working-age people to consider. Disability insurance does not cover the cost of
Some employers offer group disability insurance and this may be one of the
benefits where individual work. Or the individual might be eligible for some
This insurance policy protects the insured party from legal liabilities against injury
employees.
With rare exceptions, Oregon has a "no fault" system, which means both workers
and employers are protected from the time and expense of determining who
employers to the insurance company the employer selects. The amount the
employer pays depends primarily upon a worker’s job. A hazardous job costs more
to insure than a less hazardous job. For example, a roofing company may pay
$14.31 for workers’ compensation insurance for every $100 earned by each of its
roofers, but just 18 cents for every $100 earned by its bookkeeper. On extra
Liabilities that may arise owing to diseases mentioned in Section III (C) of
Workmen's Compensation Act during the course of employment are also covered.
amounts for each hour the employee works. The money is collected by the
Business Services (DCBS) -- the state agency that oversees the Oregon workers’
ensure that benefits paid to injured workers and workers’ beneficiaries keep pace
those injuries?
Employers don’t want to lose valuable, trained employees. The most valuable
Injuries cause rates to increase. Individuals may have to pay more for car
pay more for insurance or may even have coverage canceled, if there are too
There are many indirect costs associated with accidents. For example, there may
be lost production time and damage to machinery, which are costs not covered by
insurance.
They will help their workers get appropriate medical treatment, if necessary.
The worker and employer must then file a workers’ compensation claim for
benefits if the worker sees a doctor for medical treatment or missed time from
(Form 801) available from the employer. Workers must complete page 2, then
give the form to the employer who will complete page 1. The employer will send
both pages to the insurance company. If the worker is in the hospital or cannot
complete the form due to injury, the employer can send it to the insurer without
the worker’s signature. The employer should give the worker a copy of the
completed form.
Workers should be sure to tell their doctors that the injury happened on the job
and the name of the company that insures the employer. The doctor is required to
file a report and will ask the worker to sign a portion of the form.
or she provides the worker with a list of doctors who are authorized to treat
injured workers under the contract. A worker’s family doctor or authorized nurse
practitioner may also be permitted to treat by the MCO. Employers will provide
benefits?
Generally, any injury that occurs while working (or illness due to work) that
requires the worker to see a doctor or results in disability or death may qualify for
(such as loss of hearing). A doctor must be able to verify that there is objective
medical evidence showing that an injury or disease exists and that work exposure
evaluating the claim as soon as it is received. We will notify the worker and
employer in writing when the claim has been accepted or denied. A claim number
will be assigned to the claim. A claims adjuster may contact the worker by
telephone or in writing to ask questions about the claim. Workers should have
their claim number with them when they complete any forms, see the doctor or
call SAIF. Having the claim number available will also help workers get their
It means the claim has not been accepted or denied. No decision has been made
yet.
While a claim is deferred (and also when a claim is accepted), workers will receive
wage replacement benefits, if the doctor states that the worker cannot work, and
the worker is unable to work for more than three days. These benefits will not be
paid if the claim is denied within 14 days of the day the injury was reported to the
employer.
No one should pay for medical expenses while the claim is in a deferred status. If
SAIF accepts the claim, we will pay for medical care related to the claim. If the
claim is denied, the worker or the worker’s private health insurance carrier will be
provided the worker has coverage. However, if there is a balance remaining, the
medical provider can bill the workers compensation carrier, who will pay up to the
fee schedule for certain types of medical services prescribed to reduce pain,
upheld, the amount paid to the medical provider can be held as an overpayment
and deducted from future workers’ compensation benefits with the same insurer.
payment from the worker for the medical treatment related to the claim during the
time the claim is being evaluated or if the claim is accepted. It is also important to
know that during the time the claim is being evaluated (deferred), SAIF will not
make payment for any medication the doctor may prescribe or for any other
expenses such as transportation costs for visits to the doctor’s office. Workers
should keep receipts for these expenses, as they will be paid by SAIF, in addition
to related medical bills, if the worker’s claim is accepted. If SAIF sends a worker
How do workers get reimbursed for prescriptions that they pay for?
Workers may send their prescription receipts to their claims adjusters for
reimbursement. Pharmacies can direct bill SAIF for most future prescriptions.
pharmacy program.
If SAIF has received notification of the injury, the initial check will be mailed no
later than 14 days from the date the worker informed the employer of the injury
or became unable to work because of the injury, unless the claim is denied by the
14th day. Subsequent checks are mailed about every two weeks. An attending
The wage replacement benefit checks will continue until one of the following
occurs:
The doctor approves a written offer of modified work by the employer, but the
worker refuses to take it, and the wage offered is equal to or greater than the
wage at injury.
The worker returns to modified work and receives the equivalent of a regular
SAIF may ask the worker to verify earnings after returning to modified work to
ensure that he/she is receiving the correct amount of wage replacement. A prompt
In most cases, the check will be for two-thirds of the worker’s weekly wage up to
133% of the Oregon average weekly wage. There is usually a deduction for the
The three-day wait is required by state law and acts as a form of "deductible."
disability, wage replacement benefits are paid back to the first day the worker
missed work.
weekly wage, up to the maximum that is 133% of Oregon’s average weekly wage.
(If your date of injury is prior to January 1, 2002, your maximum is 100% of the
Oregon average weekly wage.) This maximum is calculated annually using figures
from the state Employment Department. The minimum for any injured worker is
$50 per week or 90 percent of the worker’s weekly wage, whichever is less.
investigation. This may cause a delay in the decision to accept or deny a claim. By
law, insurers have 60 days from the time your employer knew of the injury to
make this decision. (If your date of injury is prior to January 1, 2002 we have up
to 90 days.)
The worker has 60 days to appeal a denial. If a claim is denied and that denial
becomes final, the worker will be responsible for payment of all medical bills. The
worker may bill his/her private health insurance company for medical treatment if
prove that an injury occurred on-the-job or that an illness was due to job-related
factors. Workers who file a workers’ compensation claim for an injury that they
know occurred off-the-job or attempt to collect wage replacement and benefits for
one job while failing to report earnings at another may be committing fraud and
could be prosecuted. For dates of injury after January 1, 2002, some medical
benefits may be paid while the claim is on appeal. Contact your adjuster if you
A SAIF claims adjuster is available to assist the worker with his/ her claim.
receive any forms or letters that are confusing. Workers should also keep their
help.
should cooperate fully with those who are helping to return them to work. They
treatment plan. They should avoid any activities that will slow or stop recovery.
It is important for workers to keep their employers informed about their condition.
Employers need to know what the worker’s doctor reports after each medical visit.
When the doctor releases the worker for work, the worker must contact the
The intent of the workers’ compensation system is to help injured workers get
back to work. Workers have a responsibility to make every effort to return to work
once they are able. Employers may also ask an injured worker to return to a
different job while they are healing. Studies show that most injured workers
If the worker is unable to return to his/her old job and has a permanent disability,
he/she may be eligible for the Preferred Worker Program that provides financial
incentives to employers who hire injured workers with permanent disabilities. The
Department of Consumer and Business Services will notify workers if they are
Retraining is one of the last options exercised to get an injured worker back to
work. In most cases, re-employment depends upon the worker’s existing skills and
physical capabilities. If a worker believes his/her injury will prevent him/her from
returning to any employment he/she has held in the past, the worker should
Why do insurers send out all that paperwork inquiring about a worker’s
This information is needed to ensure that the benefits the worker receives are
compensation?
Employers can certainly help answer questions workers may have. Any worker
who has filed a claim with SAIF should contact us at 1-800-285-8525. They can
also call the Department of Consumer and Business Services Injured Workers'
1271.
This insurance offers limited coverage. It pays a fixed amount for each day, up to
expenses. Usually, the amount the individual receive will be less than the cost of a
hospital stay. Some hospital indemnity policies will pay the specified daily amount
even if patient has other health insurance. Others may coordinate benefits, so that
the money patient /insured receive is not equal / more than 100 percent of the
hospital bill.
Long-term care insurance is designed to cover the costs of nursing home care,
which can be several thousand dollars each month. Long-term care is usually not
covered by health insurance except in a very limited way. Medicare covers very
few long-term care expenses. There are many plans and they vary in costs and
Coinsurance
insurance company pays 80 percent of the claim, patient / insured pay 20 percent.
Coordination of Benefits
under more than one group plans. Benefits under the two plans usually are limited
Co-payment
It is another way of sharing medical costs. Here Individuals pay a flat fee every
time he receives medical service. (For example, $5 is paid for every visit to the
Covered Expenses
for all services. Some may not pay for prescription drugs. Others may not pay for
mental health care. Covered services are those medical procedures the insurer
Customary Fee
Most insurance plans will pay only what they call a reasonable and customary fee
for a particular service. If patient’s doctor charges $1,000 for a hernia repair while
most doctors in that area charge only $600, patient will be billed for the $400
expected to pay.
Deductible
The amount of money insured must pay each year to cover medical care expenses
Exclusions
Specific conditions or circumstances for which the policy will not provide benefits.
Prepaid health plans. Insured pay a monthly premium and the HMO covers
doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-
rays, and therapy. Insured must use the doctors and hospitals designated by the
HMO.
Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and
The most money insured will be required pay a year for deductibles and
to regular premiums.
doctors and hospitals that are part of the PPO, he can have a larger part of
medical bills covered. Patient can use other doctors, but at a higher cost.
Pre-existing Condition
A health problem that existed before the date insurance became effective.
Premium
coverage.
problems, and refers the patient to specialists if another level of care is needed. In
many plans, care by specialists is only paid for if the patient is referred by primary
care doctor. An HMO or a POS plan will provide a list of doctors from which patient
will choose primary care doctor (usually a family physician, internists, obstetrician-
new primary care doctor if his current one does not belong to the plan. PPOs allow
members to use primary care doctors outside the PPO network (at a higher cost).
Provider
Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides
Third-Party Payer
Any payer for health care services other than the patient / insured. This can be an
companies such as HMOs and PPOs that are trying to reign in doctors' fees.
Medical billing involves preparation of medical bills on behalf of the doctor for the
treatments performed on the patients. The work also involves sending the
medical bills to the respective insurance company with whom the patient is a
beneficiary. The billing department also collects the money from the insurance
company on behalf of the doctors. The insurance company pays for the treatments
The Medical Billing industry is a subsidiary of the Health care industry. Medical
practices. This means maintaining all of the physician’s non-medical records and
payment collections?
1. The first difference is that few people in India have a medical insurance
policy. They pay their medical fee out of their pockets immediately after their visit
to the doctor. On the other hand, a large percentage of the American population
had Medical Insurance Policies to cover their medical bills. In addition, most
physicians extend credit. In short, insurance companies pay most medical bills,
2. Even if a person has a medical insurance policy in India, and if his policy
covers his treatment, he has to pay the medical bill out of his pocket at the time of
his treatment. His insurance company then later reimburses him. In the U.S, the
patient undergoes his treatment, gives all relevant information regarding his
American law, it is the physician’s responsibility to collect the money from the
collecting payments due from the private insurance companies also as an added
America has more than 3000 insurance companies, each with a number of plans.
This posed a problem to the physicians. Every insurance company required the
medical claims filed to them according to their own rules and formats. Also, when
physicians sent out claims to these insurance companies the explanation of the
diagnosis and the treatment, necessary to every claim, were voluminous and time
consuming.
The forms and codes developed by Center for Medicare and Medicaid Services
volume was still considerable and required skill and time. The medical treatment
performed still had to be encoded. These codes, with the patients’ demographic
information, still had to be entered into specific medical billing software’s. This
process was again time consuming and the extra personnel and infrastructure
meant extra costs. They could not handle the volume and turned to specialist
billing office so that he could concentrate on his practice. Thus the medical billing
companies.
physicians’ office. Using these codes and forms, the billing office bills the
medical billing was usually done by typing out and mailing claims to various
insurance companies. Now the objective of the medical billing industry is to offer
fast, efficient, and error-free claims processing using computers to log and
What is a Claim?
A claim is a request made to the insurance company, by the billing office on behalf
the physician. A claim is sent out on standardized forms that contain information
regarding the patient, his insurance coverage, the physician, the diagnosis and the
company.
In a small family practice or suburban clinic this task may be simple and assigned
to the medical assistant or nurse but in bigger practices and clinics this is the
medical biller's job! When a physician treats a patient, the doctor’s office must file
an insurance claim to get paid. This claim is usually filed on paper and sent by
mail. These paper claims are notoriously slow, often taking 60-90 days or more for
time and money. With electronic claims processing, payment time is drastically
Medical billers and coders usually work forty regular office hours from Monday
professional healthcare office. They must know the different methods of billing
The work area of medical billers and coders usually is in a separate area away
from the patients and public eye. However, even though they are not involved in
the actual process of doctors and healthcare professionals providing medical care
they need to possess excellent customer service skills when it comes to making
contact with clients, insurance companies, and often patients. Medical billers must
know how to explain charges, deal with criticism, give and receive feedback, be
is asking questions. Patients can quickly become frustrated when trying to deal
Managed Organizations) related insurance, where the patient makes a small co-
payment at the time of service and the doctor bills the managed care company for
the balance, a number of patients still need to make arrangements to pay for their
medical services over a period of time. Part of the medical biller and coder's job is
to contact some of these patients from time to time regarding a past due bill.
Incoming calls from patients who have questions regarding a bill are also directed
to the medical billers office. The way s/he communicates over the phone can make
• Billing Coordinators
• Reimbursement Specialists
• Medical Collectors
Billing office is a link between the Doctor and the insurance company. The billing
1. Scanning Department
3. Cash Department
5. Quality Department
Scanning Department
This department is responsible for collecting the data scanned from the US billing
office. The US office in turn receives the data from the physician’s office,
office in India. The data sent to us involves the details of the patients and
treatments taken at the hospitals. (Patient Demographic & charge sheets). These
data are handled by the charge entry department. The second form of data is the
data sent to us by the insurance companies. The data contains the benefit paid to
the respective patient’s by the insurance companies and this data is handled by
the cash department. The third form of data is called the regular mails and this
comes from the insurance companies and this is handled by the accounts
receivables.
This department is responsible for registering the patients in the system before
Each type of ailment or disease has a unique diagnosis code called ICD-9 code
involved in the treatments are noted by unique codes called the CPT (Current
The charge sheets notify the various treatments performed on a patient. The
charge entry department enters these procedures into the respective patient
account. These details are collected and entered by the billing office and the
copies of these claims are sent to the insurance companies. The mode of sending
Patient Demographics & charge entry is the first step of the billing process and an
error here will prompt errors in the subsequent steps. In some cases this error
can be discovered only after the claims reach the insurance carriers. This will
result in lost accounts receivables time. Hence utmost care should be taken while
This department is responsible for entering the cash details into a particular
account. The check and the explanation of benefits (EOB) are sent to us by the
insurance companies. Check contains the providers or group name, amount paid
and the insurance company’s name. EOB contains the detailed description of the
payments made for the type of procedures involved in the treatment. In case of a
denial, an EOB alone is sent and it explains which charge has been denied and for
what reason. EOB will be used to verify any discrepancies from the expected
payment.
When a claim has been processed and paid, the amount paid will have to be
applied to the amount charged for individual patient’s treatment in the Medical
billing software. This makes it possible for the billing office to track the payments
received from different angles. Some examples of how a billing office would want
c) Total payments made for all patients or any group of patients (grouped by
f) All payments made for one particular treatment that the physician renders.
the medical billing software is very important as any wrong posting may result in
wrong accounting. If there are any mistakes in posting, the reports that are run
incorrect.
EOB’s are the only hard copy evidence the billing office have to check how the
insurance company had processed the claims sent to them and it has to be filed
This department has to check for the steady inflow of money from the insurance
company. The main motive of this department is to collect money for all the
treatments taken by the patients. Usually the turn around period for the payment
department has to make an enquiry for the delay. There are various reasons for
a) Correct details may not have been provided to the insurance companies.
b) Claims were sent correctly but Insurance Company may not have received
the claims.
c) The checks issued might have been sent to the wrong address.
d) The insurance company may delay the payments if they have a backlog and
they would inform us by a letter that they have received the claims and
This department can gather & update lot of billing information which is required to
settle a claim. There are instances where insurance company does not make a
100% payment and we would have received a low payment, in such case AR
The Medical billing software is capable of running reports that pull out claims that
are unpaid for greater than 30 days. These are calling aging reports and show
pending payments in slots such as 0 – 30 days, 31-60 days and 61-90 days.
Claims filed within the last 30 days will find themselves in the first slot (0-30days).
Claims that are more than 30 days but less than 60 days old will be found in the
31-60 days slot. A glance at this report will show the AR personnel the claims that
would be necessary to find out why the claims are yet to be paid and what needs
to be done to have these claims paid. The delay and denials will be corrected by
the billing office in coordination with the physician’s office and the insurance
carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in
that time, the billing office will follow up with the patient.
number of circumstances where these departments will have to work with each
departments will assure correct and quick payments from both the insurance
accurate with the information received, this will also enable the claim to be paid
within the given time period. Next comes “Timely Response i.e., work received
has to be completed within the stipulated time period as agreed with the client.
In the absence of correct checks and balances, companies can run the risk of
jeopardizing their relationship with customers through the inability to provide
continuously good service.
The project is initiated with formal identification of the Project Manager, allocation
monitoring is done through various levels of quality reviews. The project manager
Demos:
Patient Details:
7. Patient Address:
9. Employer Details.
Guarantor Details:
1. Guarantor Name.
2. Guarantor Address
3. Guarantor Phone#.
Insurance Details:
Primary Insurance:
1. Plan Name.
2. Insurance Address
3. Policy Number
5. Subscriber
6. Relationship code
Charges:
2. Place of Service
3. Facility
4. Referring Doctor
5. Provider
6. Procedure
7. Modifiers
8. Diagnosis
9. Units
to piece together a puzzle with a lot of pieces. Not only is there a lot of
1. Providers are using invalid, obsolete or deleted codes while submitting claims to
2. The code and fees may be okay, but providers may be losing charge
irregularly.
3. The practice is not well-informed about current coding and billing issues.
4. The practice doesn't have and/or doesn't follow written policies and procedures
5. Not participating in Medicare may allow providers to bill higher fees to patients,
7. The practice is not using forms and documents which are current.
In general, the basic tools needed by health care providers for optimizing
reimbursement are:
The following brief outline would give the workflow process from the time a patient
is seen by a physician.
2. Billing office scans the source documents and saves the image file to an FTP
site or on to their server under pre-determined directory paths.
3. Scanning department retrieves the files and prints them and ties up with
the control log for number of files and pages. (This process is absent if a billing
office opts for data entry thru electronic source documents)
4. Illegible /missing documents are identified and a mail is sent to the Billing
office for rescanning.
6. Coding and pre-coding of the super bill/charge sheet and demographics for
insurance, doctors, modifiers, CPT and diagnosis are done wherever required.
8. Charges are checked for accuracy and again verified by audit department
for accuracy and compliance with rules.
10. Cash Application team receives the cash files and the deposit control log is
prepared. This helps to reconcile the deposits at the end of each month. During
cash application overpayments are immediately identified and necessary refund
requests are generated for obtaining approvals. Also underpayments/denials are
highlighted for further research by the denied claims team.
11. All denied codes in the EOB’s or Explanation of Benefits received are
researched by the rejected/denied claims group, which will determine the reason
for denial, and appropriate action is initiated for resolving the issue. This group
also researches the regular mail received from the insurance companies and
appropriate actions are taken on the refund request, newsletters, rejection reports
etc.
12. AR analysts are the key to any group. They record the processing time of
each insurance companies and identify all claims falling above the processing time.
13. Insurance calling team initiates calls to the insurance companies to establish
reasons for non-payment of the claims. All reasons are passed on to the Analysts
for resolution. Calling team works during the American Time zones.
14. Patient calling team calls up the patients to confirm receipt of bill and when
they are going to pay. Based on client’s approvals budget plans and discounts for
immediate payments are also undertaken.
Below chart will clearly demonstrate the actual flow of medical billing process.
Process starts right from the stage of patient demographic entry at the physician’s
If secondary or tertiary
Other
Insurance available, Client Adjustments
Appeals actions
submit claims Assistance
If Claims
needs to be
If Claim needs to be submitted
A submitted in paper
B
electronically
Billing
office in
Billing
India
office in
U.S
Eligibility
Verification
Clearing
House
Patient
registration
Conversion in & Charge
Preliminary entry
to ins. Specific
screening Dispatch
format
Cash
Posting
A/R
Department
Insurance Company
Claim
Communication
Adjudicatio Pre-edit/Audit
of Decision
n
Every Healthcare Provider that delivers a Service receives money for these
services by filing a claim with patient’s Health Insurance Carrier. This is also
Codes exist for all types of encounters, services, tests, treatments, and procedures
headaches, upset Stomach, etc have codes which consist of a set of numbers and
a combination of set of numbers. The Combination of these codes tells the payer
what was wrong with patient and what service was performed. This makes it
easier to handle these claims and identify the provider on a predetermined basis.
Coding Systems
(ICD-9-CM)
CPT and ICD-9-CM are not the only coding systems. Here are few more coding
1. CDT-3 codes
2. ABC codes
3. SNOMED codes
4. NDC codes
6. DRG systems.
intervals. The most recent version is ICD-10, which was published in 1992. WHO is
In US, the coding is still based on ICD-9-CM, which contains more detailed codes.
are the minimum requirement for reporting the reason for the
detail. At all levels, the numbers 0 to 7 are used for further detail,
whereas the number 8 is reserved for all other cases and the
The basic ICD is meant to be used for coding diagnostic terms, but ICD-9 as well
as ICD-10 also contains a set of expansions for other families of medical terms.
For instance, ICD-9also contains a list of codes starting with the letter “V” for
reasons for encounter or other factors that are related to someone’s health status.
A list of codes starting with the letter “E” is used to code external causes of death.
The disease codes of both ICD-9 and ICD-10 are grouped into chapters. For
example, in ICD-9, infectious and parasitic diseases are coded with the three-digit
codes 001 to 139, and in ICD-10 the codes are renumbered and extended as
codes starting with the letters A or B; for tuberculosis the three-digit codes 010 to
018 are used in ICD-9, and the codes A16 to A19 are used in ICD-10. The four-
Example of a Four-Digit Code Level in ICD-9 and the Five-Digit Code Level as
Extended by the ICD-9-CM
Code Disease
001 - 139 Infectious and parasitic diseases
001 - 009 Infectious diseases of the digestive tract
003 Other Salmonella Infections
- 003.0 Salmonella gastroenteritis
- 003.1 Salmonella Septicemia
- 003.2 Localized Salmonella Infections
- 003.20 Localized Salmonella Infection,
Unspecified
- 003.21 Salmonella Meningitis
- 003.22 Salmonella Pneumonia
- 003.23 Salmonella Arthritis
- 003.24 Salmonella Osteomyelitis
003.29 Other Localized Salmonella
-
Infections
- 003.8 Other Specified Salmonella
Infections
- 003.9 Salmonella Infections, Unspecified
The U.S. National Center for Health Statistics published a set of clinical modifications to ICD-
9, known as ICD-9-CM. It is fully compatible with ICD-9, but it contains an extra level of
detail where needed. In addition, ICD-9-CM contains a volume III on medical procedures.
descriptive terms and identifying codes for reporting medical services and
The American Medical Association (AMA) first developed and published CPT in
1966. The first edition helped encourage the use of standard terms and
statistical purposes.
The first edition of the CPT code book contained primarily surgical procedures,
The second edition was published in 1970, and presented an expanded work of
medicine, and the specialties. At that time, five-digit coding was introduced,
In the mid- to late 1970s, the third and fourth editions of the CPT code were
keep pace with the rapidly changing medical environment. In 1983, the CPT code
Common Procedure Coding System). With this adoption, CMS mandated the use of
HCPCS to report services for Part B of the Medicare Program. In October 1986,
CMS also required State Medicaid agencies to use HCPCS in the Medicaid
Reconciliation Act, CMS mandated the use of CPT for reporting outpatient hospital
Medicaid), CPT is used extensively throughout the United States as the preferred
codes listed. Frequently there are additional instructions for code use in
physician offices, need only Volumes 1 and 2. Thus, books that contain only
editions.
are used for billing inpatient hospital stays in the DRG system so books that
other services.
4. NCCI Manual
1. Charge sheets that must be coded are, upon receipt by the billing account,
2. Medical coders code the diagnosis description given in the charge sheets
4. Coding policies and guidelines, if any, established by the client, the coding
decides that the errors are of such a type that will require client
6. When a coder finds that the information on the charge sheet is insufficient
7. When a given diagnosis code is not in the list of covered diagnosis codes
listed in the state Medicare carrier’s LMRP (Local Medical Review Policy), the
coder will code the diagnosis as documented and write “Not in LMRP” in the
client, except when there are definite errors, such as typographical errors.
10. Upon completion of coding, the coded charge sheets are forwarded to
11. The work of new coders who join the department will be fully audited
before file submission, until such time the coders gain the required level of
accuracy.
12. A hundred percent audit of all coding work can be conducted during project
transition, until such time the coders gain the required experience and
accuracy levels.
Coding guidelines
Refer all medical records of patients treated for multiple trauma and
2. Consult the following sources to identify all diagnoses and procedures requiring
sheet.
coded.
coding.
supervisor.
V codes are used to identify encounters for reasons other than illness or
openings (V55). For inpatient coding, avoid the use of V codes as the
currently ill obtains health services for a specific purpose, such as, to act
Avoid using codes that lack specificity. These vague codes should not be
specific code.
Inpatient coding requires that signs and symptoms are coded when a
Code the condition for that visit, i.e., signs or symptoms or abnormal
test results.
treatment.
Codes.”
statements(s).
absence of these parenthetical terms in the diagnosis has no effect upon the
3. Refer to any sub terms indented under the main term. These sub terms for
clinical type.
7. Fourth and fifth digit sub classification codes must be used where provided.
component elements are fully identified. This instruction applies even when
9. Use both codes when a specific condition is stated as both acute (or sub
acute) and chronic and the Alphabetic Index provides unique codes at the
10. The term hypertensive means “due to”, but the presence of words
the cause but do not assign a code for the sign or symptom.
for the symptom as well as for the diagnoses. When coding outpatient
reasons.
14. V codes are found in the Alphabetic Index under references such as
assign codes for both the endoscopy and the procedure unless the code
endoscopic/laparoscopic approach.
canceled surgeries to V64.1, V64.2 and V64.3. use code V64.1 if a closed
18. Do not assign the code for primary malignancy or unspecified site if
the previous primary site by assigning the appropriate code in category V10
identified as metastatic, code as primary site unknown and also assign the
22. Code only the most severe degree of burn when different degrees of
23. Assign separate codes for multiple injuries unless the coding books
28. When the late effect of an illness or injury is coded in the main
classification, the E code assignment must also be one for late effect.
Patient Demographics sheet contains all the basic demographic information about
important because correct and quality entry of such information will directly
impact physician’s monthly revenue. This sheet is also called as face sheet of a
charge or claim.
will reduce the insurance company’s need to contact billing office. Avoiding
unnecessary contact will reduce the costs of claims processing and delay in
payments. Obtaining all the required demographic information will often determine
how willing the patient is to complete the form. If the request is firm and
policy which was in effect during their last visit. Photocopy of insurance cards is
always a help.
Patient Demographic sheets also known as face sheet are distributed to patients
when they visit physician’s office for treatment. Before the services are rendered,
front office staff ensures that patient demographic sheets are filled in by the
patient or some one in patient’s family. This process ensures that all necessary
office, copies of insurance identification card are also taken. This is to ensure that
Insurance ID card contains very valuable information which would be very helpful
These patient demographics are batched together at physician’s office and are
They are:
I. Patient Information.
V. Insurance Information.
I. Patient Information
They are:
1. Account #
2. Patient Name
3. Patient Sex
5. Marital Status
6. Patient Address
identified in the system. Before filing any claim we would need to obtain clear,
accurate information from the patients. A good patient information sheet is the
key to this aspect of claims submission. Let us now see few more things about
1. Account Number [Visit Number]: In case of a New Patient this field in almost
all the Medical Billing software’s is updated automatically. In cases where it does
not get updated automatically the billing office enters the Medical Record
Hospital/Provider.
In case of an Established Patient the Billing Office runs a query to search for
the patient record with the help of the Medical Record Number/Account Number or
using the Last Name or using the Date of Birth of the patient. If the software has a
Visit Number concept then a new visit with the same Account number and the next
visit number is created if not then the same Account is edited with the new details
This number is for the internal purpose of the Billing Office and the Hospitals.
This field is usually in numeric format but may differ from software to software.
This number does not form part of the CMS-1500 claim form.
Example:
format. However in some software’s this field is split as Last Name First Name and
Middle Initial fields. The patient name may also contain title (Junior, Senior, I, II,
III …) and suffix (M.D. …) this information also needs to be entered along with the
name. The title must be entered with the last name and the suffix should be
entered with the first name or after the middle initial. The Name on the Encounter
Form may not be given in above said format but still it should be entered as per
the Billing Software specifications. Checking the spelling of patient name is a very
Patient name is printed in the 2nd field of the CMS1500 form in Last Name,
Example:
3. Date of Birth: This field contains the Date of Birth of the patient. It is entered
This field is printed in the 3rd field of the CMS-1500 claim form in MM DD YY
format. If Date of Birth detail is not available then generic DOB format have to be
Example:
Female, and U for Unknown when the gender of the patient is not specified on the
This field is printed in the 3rd field of the CMS-1500 claim form along with the
Example:
5. Social Security Number: This field contains a 9 digit number which is allotted
to the patient by the Social Security Administration. If SSN is missing from patient
encounter form then this field is usually left blank or any 9 digit dummy number
Example:
The Social Security Act was signed by President Franklin Roosevelt on August 14,
1935. Taxes were collected for the first time in January 1937 and the first one-
time, lump-sum payments were made that same month. Regular ongoing monthly
The term was first used in the U.S. by Abraham Epstein in connection with his
group, the American Association for Social Security. Originally, the Social Security
Act of 1935 was named the Economic Security Act, but this title was changed
during Congressional consideration of the bill. Under the 1935 law, Social Security
only paid retirement benefits to the primary worker. A 1939 change in the law
added survivor’s benefits and benefits for the retiree's spouse and children. In
iii. Who assigns the SSNs and how many SSNs have been assigned?
were first issued in November 1936. By December 1, 2002 more than 418 million
program?
Yes. Under the 1935 law, Social Security only paid retirement benefits to the
primary worker. A 1939 change in the law added survivor’s benefits and benefits
for the retiree's spouse and children. In 1956 disability benefits were added.
Social Security is not just a program for the elderly and disabled. Survivors of
deceased workers and the families of retired or disabled workers also qualify for
benefits. In fact, about 3.8 million children are currently receiving such benefits
disabled, or dies. They need a Social Security number (SSN) before they can
receive benefits.
The SSN is also needed for reasons not connected with Social Security benefits.
Security Number?
The digits in the Social Security number allow for the orderly assignment of
numbers. The number is divided into three parts: the area, group, and serial
determined by the ZIP Code of the mailing address shown on the application for a
northeast and moving westward. So people on the east coast have the lowest
numbers and those on the west coast have the highest numbers. The remaining
six digits in the number are more or less randomly assigned and were organized to
facilitate the early manual bookkeeping operations associated with the creation of
Within each area, the group number (middle two (2) digits) range from 01 to 99
but are not assigned in consecutive order. For administrative reasons, group
numbers issued first consist of the Odd numbers from 01 through 09 and then
Even numbers from 10 through 98, within each area number allocated to a State.
After all numbers in group 98 of a particular area have been issued, the Even
Within each group, the serial numbers (last four (4) digits) run consecutively from
SSA does not reissue SSNs after someone dies. When someone dies their number
is simply removed from the active files and is not reused. In theory, the time
might come someday when SSA would need to consider "recycling" numbers in
numbers since the 9-digit Social Security number allows about 1 billion possible
combinations, and to date SSA have issued a little over 400 million numbers.
viii. How can one get a different Social Security number assigned to
himself?
Generally, an individual is assigned only one Social Security number (SSN) which
is used to record the individual’s earnings for future benefit purposes and to keep
track of benefits paid under that number. However, under certain circumstances,
SSA may assign an individual a new (different) SSN. When they assign a new
number, the original number is not voided or deleted. For integrity reasons, they
cross-refer in the records all the numbers assigned to the same individual.
SSA can assign new SSN in the following situations, provided all of the
• Misuse by a third party of the number holder’s SSN and the number holder
violence)
To apply for a new (different) SSN, you need to complete Form SS-5 (Application
You will also need to submit evidence age, identity, and U.S. citizenship or lawful
alien status. Form SS-5 explains what documents will satisfy these requirements.
You will also need to submit evidence to support your need for a new number.
If you are age 18 or over, you must submit your request for a new SSN in person
ix. When did Social Security cards bear the legend "NOT FOR
IDENTIFICATION"?
The first Social Security cards were issued starting in 1936; they did not have this
legend. Beginning with the sixth design version of the card, issued starting in
1946, SSA added a legend to the bottom of the card reading “FOR SOCIAL
removed as part of the design changes for the 18th version of the card, issued
beginning in 1972. The legend has not been on any new cards issued since 1972.
The easiest way to apply for a baby's Social Security number (SSN) is at the
hospital. Both parents’ Social Security numbers are required when applying for a
baby’s SSN. When a parent requests a Social Security number (SSN) for his/her
newborn as part of the birth registration process in the hospital, the State Vital
Statistics Office forwards to the Social Security Administration (SSA) data we need
to assign an SSN to the child and issue a card. This is known as the Enumeration
at Birth (EAB) process. Once SSA receives the data, the process of assigning the
number and issuing the card is the same as if the application were taken in a
In most States, the birth registration process is electronic. Hospitals submit birth
completed and EAB data is sent to the Social Security Administration within 60
days of birth. EAB is a good service for most parents who have no immediate need
for their child's SSN because they do not have to submit an application and
SSA issues three types of Social Security cards depending on an individual's citizen
only. This is the card most people have and reflects the fact that the holder can
work in the U.S. without restriction. SSA issues this card to:
- U.S. citizens, or
- Non-citizens who are lawfully admitted to the U.S. for permanent residence,
record to work permanently in the U.S., such as refugees, asylees and citizens
The second type of card bears, in addition to the individual's name and Social
Security number, the legend, "NOT VALID FOR EMPLOYMENT". SSA issues this
benefit; or
- are legally in the U.S. and don't have DHS permission to work but, are
subject to a state or local law which requires him or her to provide a SSN to
get general assistance benefits or a State driver's license for which all other
The third type of card bears, in addition to the individual's name and Social
Security number, the legend, "VALID FOR WORK ONLY WITH INS (or
DHS) AUTHORIZATION". SSA issues this card to people who have DHS
If you’re a non-citizen, SSA must verify your documents with DHS before SSA
issues a SSN card. SSA will issue the card within two days of receiving
online with DHS. If DHS can’t verify your documents online, it may take several
An invalid (or impossible) Social Security number (SSN) is one which has not yet
been assigned.
The SSN is divided as follows: the area number (first three digits), group number
(fourth and fifth digits), and serial number (last four digits). To determine if an
• No SSN with an area number in the 800 or 900 series, or "000" area number,
• No SSN with an area number above 728 have been assigned in the 700 series,
• No SSN with a "00" group number or "0000" serial number have been
assigned.
SSA discourages the lamination of Social Security number (SSN) cards because
fraud and misuse involving SSN, SSA currently issues SSN cards that are both
white; intaglio printing in some areas on the front of the card; and yellow, pink,
and blue planchets--small discs--on both sides). SSA cannot guarantee the validity
of a laminated card. You may, however, cover the card with plastic or other
SSA would also recommend that as a security precaution, you carry your Social
Security card only when you expect to need it, for example, to show to an
Social Security does not charge a fee for either an original or replacement Social
Security card. A replacement card can be a duplicate card (one with the same
name and number) or a corrected card (one with different name but the same
number).
The official verification of your Social Security number is the card issued by the
Social Security Administration. Third parties who request your Social Security card
as verification of your number will want to see the card SSA issues. Although
Social Security has no authority to prevent use of metal or plastic replicas of Social
Security cards, SSA considers them an unauthorized use of the Social Security
No. When someone has applied for and been assigned a Social Security number
(SSA) may not cancel or destroy that record. The Privacy Act of 1974 authorizes
law. SSA is required by law to establish and maintain records of wages and self-
employment income for each individual whose work is covered under the program.
The SSN is considered relevant and necessary for that record keeping purpose.
6. Marital Status: This field contains the Marital Status of the patient. It is
usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for
Widow/Widower, ‘X’ for Separated and ‘O’ for Others. It marital status is missing
from patient encounter form, we need to enter ‘O’ in the marital status field.
This field is printed in the 8th field of the CMS-1500 claim form.
Example:
State and ZIP code. This field can not be left blank. Patient address is a
c) Blvd. - Boulevard
d) Ste. - Suite/Street
e) Dr. - Drive
This field is printed in the 5th field of the CMS-1500 claim form.
Example:
Apt. # 194
8. Patient Phone Number: This field contains the contact number of the patient
including the area code. It contains a total of 10 digits (111-222-3333), the first 3
digits are the area code, and the next 7 digits are the phone number of the
patient. If the area code is not specified the phone number can still be entered
leaving the area code field blank or entering some dummy number as per the
This field is printed in the 5th field of the CMS-1500 claim form along with the
address.
Example:
This segment in the face sheet contains employer information of the patient. The
entry person needs to enter this information if available in face sheet. Employer
information is a must for worker’s comp claims. Non-worker’s comp claims do not
1. Employer Code
2. Employer Name
4. Designation/Occupation
5. Contact Person
1. Employer Code: This field is used in most of the Billing Software’s to reduce
the time of PD entry. The Names and Addresses of the major Employers are stored
in the Employer database with a unique code assigned to each employer. Hence it
is enough to just enter the code and skip to the next block.
Example:
This field is printed in the 11b field of the CMS-1500 claim form.
Example:
Example:
4. Employer Phone Number (Ext No.): This field contains the contact number
of the patients Employer including the area code. It contains a total of 10 digits
(111-222-3333), the first 3 digits are the area code and the next 7 digits are the
phone number of the patient. If the area code is not specified the phone number
can still be entered leaving the area code field blank or entering some dummy
number as per the Billing Software specifications. Some software’s may also
require you to enter the Extension number if given on the encounter form.
Example:
information.
They are:
1. Guarantor Account #
2. Guarantor Name
3. Guarantor Address
4. Guarantor phone #
5. Guarantor/patient relationship
This block is mostly entered only in the case of the patient being a minor or if
the patient is not responsible for the payment. This information is for the internal
purpose of the Billing Office and the Hospitals for the purpose of Emergency
Contact or follow-up of pending balances and hence does not form part of the
the guarantor is already stored in the database then the stored information can be
pulled up using this number. This information is not part of the encounter form.
2. Guarantor Name: This field is entered in the Last Name, First Name Middle
Initial format. However in some software’s this field is split as Last Name First
Name and Middle Initial fields. The guarantor name may also contain title (Junior,
Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered
along with the name. The title must be entered with the last name and the suffix
should be entered with the first name or after the middle initial. The Name on the
Encounter Form may not be given in above said format but still it should be
Example:
3. Relationship: This field contains the relationship of the Guarantor with the
Example:
Example:
Heathsville, GA 65418
including the area code. It contains a total of 10 digits (111-222-3333), the first 3
digits are the area code and the next 7 digits are the phone number of the patient.
If the area code is not specified the phone number can still be entered leaving the
area code field blank or entering some dummy number as per the Billing Software
specifications.
Example:
(517)373-1820; 517-374-5857 …
information. Basically the guarantor’s employer name, address, and contact details
7. Emergency Contact: This field is used to enter the Emergency Contact details
of the patients relative or next of kin. Contact information such as Name, Address
patient to a hospital or other inpatient health facility. Some facilities have all
(Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are
stored using a unique code in the provider database. Hence while selecting a
physician codes the entry person should be very careful to select the correct code
after cross checking all the relevant details. This field is optional; if the Admitting
This field does not form part of the CMS-1500 claim form.
Example:
portion of care or having primary responsibility for the care of the patient's major
condition or diagnosis. In other words the doctor or supplier who actually renders
related to a particular physician (Physician Name, UPIN, Federal Tax ID, License
#, Facility Address & Phone #) are stored using a unique code in the provider
database. Hence while selecting a physician codes the entry person should be very
careful to select the correct code after cross checking all the relevant details.
The Name of the rendering physician is printed in the 33rd field along with the
Address and Phone #. The rendering physician’s Federal tax ID stored in the
database is automatically printed in the 25th field of the CMS-1500 claim form.
sent the beneficiary to another physician or, in some cases to a supplier (e.g.,
called a referring Physician or Primary Care Physician (PCP). The name of the
facility may be reflected in this area if the patient has not identified a unique
physician, but has identified a facility. All the information’s related to a particular
physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address &
Phone #) are stored using a unique code in the provider database. Hence while
selecting a physician codes the entry person should be very careful to select the
The name of the referring physician is printed in the 17th field and the
corresponding UPIN stored in the database is printed in the 17a field of the CMS-
V.Insurance Information
sheet. Information found in this field should always be the updated & correct one.
always match this information with copy of insurance id cards. (if provided). This
1. Insurance Code/Name
2. Effective Date
3. Subscribers Name
4. Relationship Code
5. Pre-Certification/Pre-Authorization
6. Referral Number
8. Date of Injury/Accident
9. Claim Number
1. Insu
rance
coverage that the patient has. The insurance code is assigned by the Billing office
for its internal purpose to reduce the PD entry time. Each Insurance company’s
name, billing address, contact person, etc… are assigned a unique code. The entry
person should be very careful while selecting the insurance code and should
always verify the billing address with the given card copy or with the billing
The Primary insurance name is printed in the 11c field and the Secondary
Example:
2. Effective Date: This field contains the effective date of coverage. This date
should not be after the Date of Service. The date format is MMDDYYYY. This date
is used for the internal purpose of the Billing office and Hospitals. This does not
Example:
3. Subscribers Name: This field contains the Subscribers name of the insurance
policy. If the patient is a dependant who is covered under someone else’s policy
then the name of the person who pays the premium is entered in this field. If
patient is the subscriber then we need to enter the patient name itself. The name
Secondary insurance subscribers name is printed in the 9th field of the CMS-1500
claim form.
Example:
4. Relationship Code: This field contains the relationship of the subscriber to the
5. Policy ID: This field contains the Policy number given by the insurance
company to the subscriber and the dependants of the policy. This does not have
any standard format across the insurance company but each insurance company
has a unique format such as for Medicare the policy number is given as SSN +
printed in the 11th field and the Secondary insurance ID is printed in the 9a field of
Example:
6. Group ID: This field contains the Group ID as given by the insurance company
for the policy. Not all the insurance companies have the Group ID hence if not
care before admission. This refers to a decision made by the payer, Managed Care
evaluating the need for service prior to the service being rendered. The practice of
reviewing claims for inpatient admission prior to the patient entering the hospital
in order to assure that the admission is medically necessary. The third party
usually reviews the treatment plan, monitoring one or more of the following:
are expected to exceed a certain amount. This number should be attached with
the respective claim; otherwise the claim will be rejected. There is no standard
format for Auth and Pre-Cert. number across all the insurance companies. Each
insurance company has its own unique format of Auth and Pre-Cert. numbers.
patient cannot get a specialist’s service if he has a HMO plan. This number is
printed on the CMS-1500 claim form or entered in the attached documents as per
This date is useful for the insurance companies to verify if the coverage was active
or not. This date is mentioned in the documents attached while filing the claim.
10. Claim Number: This field is used to enter the Claim number for a particular
mention this number on the claim form will result in the rejection of the claim.
Patient charge is nothing but the fees claimed by the physician who rendered the
services to the patient. Charges can be either based upon demographic evaluation
or a flat fee rate as prescribed by the physician’s office. Each piece of information
is important because correct and quality entry of such information will directly
impact physician’s monthly revenue. This sheet is also called as face sheet of a
charge or claim.
the appointed time. After preliminary investigation physician provides the services
procedure code and diagnosis code denotes the nature of illness for which services
were administered.
Super bills or charge sheets contain information like Date of Service, Kind of
Service, Diagnosis Code, Attending Doctor, Modifier details. Super bills are usually
and are forwarded to our office for charge entry. Mode of transfer of data may
vary from client to client. But most preferred mode is thru FTP. Here patient
demographics are scanned & captured as image file. These image files are placed
in FTP site. These image scan files are retrieved at our office & charge entry
begins.
• For our easy understanding now let us see each of the information found in
# Of days/ units, 12. Location Details 13. Physician Name, Address, Provider id
The Rendering Physician Name, Address, and PIN are printed in the 33rd
field and if the Address of the Facility where the service was rendered
differs from the Physicians location then that address is printed in the 32 nd
simple words, the physician who has sent the beneficiary to another
the Medical Billing software which stores the Name of the Physician,
Number).
The Referring Physician Name is printed in the 17th field of the CMS-1500
claim form. The UPIN which is stored along with the code is printed in the
3. Admit Date: Admit date refers to the date in which patient was admitted
into the Hospital. For workers compensation Date of Injury (DOI) is very
important for processing the claim. For the purpose of determining the
date of injury for an occupational disease, the date of injury shall be taken
the date on which the employee first knew or reasonably should have
service and also it will be in the single date format. Standard format for
admit date.
POS can be for inpatient, Outpatient & ER. Health care that you get when
does not include an overnight hospital stay is an outpatient. Care given for
consists of the place or the location where services were provided to the
Details like location name, address are printed. Where services are
about certain medical procedures (like outpatient surgery) in order for those
guidelines and plan limitations. This will help to understand the costs if
given while entering the procedure code. We need to first know what kind
Level II codes (national codes), and Level III codes (local codes). Level I
(CPT) codes are five digit numeric codes that describe procedures and tests.
Level II (national) codes are five digit alpha numeric codes that describe
are developed and maintained by CMS with quarterly updates. Level III
(local) codes are five digit alpha numeric codes that are being phased out
• 45378 – Colonoscopy
In other words, this field contains the Code of the procedure done
among physicians, patients, and third parties. All the Procedure codes are
description of the code and the dollar amount. This helps the charge entry
This field is printed in the 24d field and the corresponding dollar amount of
the procedure stored in the Medical Billing Software is printed in the 24f
Modifiers are two digit numeric or alpha numeric codes that are appended to
component
This field is printed along with the CPT/HCPCS Code in 24d field of the
Procedure Coding System) modifiers, and local modifiers has been compiled
for reference.
sources.
definition of CPT-4 numeric modifiers with one modification. The five digit
modifiers identified in the CPT are not included in these definitions since the
text) has been added, as well as examples. Other modifiers are self-
Modifiers provide the means by which the reporting provider can indicate a
service or procedure that has been performed has been altered by some
occurred
Anesthesia
anesthesia procedures
Global Surgery
reimbursement:
service.
on May 10, 1998. The ICD-9-CM diagnosis code reported is 171.2. The post-
The patient returns to the office on May 15, 1998 and is treated for contact
e.g., 9921224.
the E/M service must be different from the diagnosis code reported for the
the surgeon following surgery. Medicare recognizes modifier 24 only for the
surgeon;
The care is for critical care (99291, 99292) for a burn or trauma patient
under
by the Same Physician on the Day of a Procedure: The physician may need
identifiable E/M service above and beyond the usual preoperative and
postoperative care associated with the procedure that was performed. The
E/M service may be prompted by the symptom or condition for which the
procedure and/or service was provided. As such, different diagnoses are not
required for reporting of thre E/M services on the same date. This
Note: This modifier is not used to report an E/M service that resulted in a
visit on the same day could be properly billed with the 25 modifier in
examination was made for a patient with head trauma. Billing for a visit
would not be appropriate if the physician only identified the need for sutures
before the service, (e.g., whether or not sutures are needed to close a
separate payment may be made for an initial hospital visit (CPT codes
and a hospital discharge service (CPT codes 99238 and 99239) when billed
by the same physician for the same date as an inpatient dialysis service
global period) which result in the initial decision to perform the surgery are
not included in the global surgery payment. These E/M services may be
This modifier should not be used for visits furnished during the global period
visit is a decision for major surgery. This modifier is not used with minor
surgeries because the global period for minor surgeries does not include the
day prior to the surgery. When the decision to perform the minor procedure
procedure.
Note: Medicare policy limits the use of this modifier to staged procedures.
The CPT-4 definition of this modifier is broader in scope. This modifier is not
The relative value units represent the work for the total number of sessions
performed within the global period of the initial surgery are included in the
global fee.
may need to indicate that a procedure or service was independent from the
modifier 59.
requires the use of the operating room, it may be reported by adding the 78
room, physicians must bill the CPT-4 code that describes the procedure (s)
performed during the return trip. If no such code exists, use the unspecified
procedure code in the correct series, e.g., 47999 or 64999. In this situation,
which will allow us to understand the extent of the service performed. The
procedure code for the original surgery is not used except when the
On March 15, 1999, the patient is returned to the operating room for a
as 4990078.
79.
Surgical
should be identified by adding the modifier 50to the appropriate five digit
code.
Report such procedures as a single line item with a unit of 1. For example,
bilateral), do NOT report the procedure code with modifier 50. For example,
Therefore it's not appropriate to report this modifier with this code.
the same session by the same provider, the primary procedure or service
service code(s).
(e.g., 22612, 22614). For more information, please reference chapter 22,
section 22.1
by adding the modifier 53 to the code reported by the physician for the
discontinued procedure.
the one day preoperative care, the intraoperative service, as well as any in-
care only, report the original date of surgery as your date of service and the
rare situations where the out of hospital postoperative care is split between
cannot bill for any part of the global services until he/she has provided at
Under some circumstances the individual skills of two surgeons are required
to perform surgery on the same patient during the same operative session.
single surgical procedure, each surgeon bills for the procedure with modifier
necessity for two surgeons is required for certain services identified by the
and various types of complex equipment) are carried out under the "surgical
is prepared for but cancelled can be reported by its usual procedure number
circumstances or those that threaten the well being of the patient, the
etc). Under these circumstances, the procedure started but terminated can
be reported by its usual procedure number and the addition of the modifier
74.
53.
adding the modifier 80 to the usual procedure number (s). This modifier
but the surgeon opted not to use the resident. In the latter case, the service
program related to the medical specialty required for the surgical procedure
Health Professional Shortage Area (HPSA) and are eligible for the 10%
incentive payment.
greater than what is usually required for the listed procedure, indicate this
those procedure codes for which the global surgery concept applies,
usual procedure number and the addition of the modifier -52, signifying that
modifier 52, include office records, test results, operative notes, or hospital
repeated service.
reported on the next line with modifier 76 appended to the procedure code.
twice, report the second line with the 76 modifier and the appropriate
number of units in the units field. If a service is repeated more than once,
claim to support the medical necessity of the repeat services. The patient's
procedure number.
test on the same day to obtain subsequent (multiple) test results. Under
Note: This modifier may not be used when tests are rerun to confirm initial
required.
This modifier may not be used when other code(s) describe a series of test
modifier may only be used for laboratory test(s) performed more than once
on the same day on the same patient. (Note: Effective for dates of service
• AH - Clinical Psychologist
Note: These modifiers can be used to specify on which eyelid services were
Note: These modifiers can be used to indicate that rebundled services were
column I & II services are performed on different digits. See Appendix C for
• G6 - ESRD patient for whom less than six dialysis sessions have been
provided in a month
• GA - Beneficiary authorization
Effective for dates of service on and after October 1, 1995, report this
and necessary under Medicare guidelines. See chapter 6, page 6-6.1 for
Note: GE, for this purpose, is for use on all services except ambulance.
using the correct chiropractic HCPCS code (98940, 89841, or 98942) along
devices and/or services incident to the use of such devices should be billed
using the appropriate HCPCS code and the QA modifier. When billing a
service with the QA modifier, you are certifying FDA approval of a clinical
trial or the device and that the device was approved at the time the service
was rendered.
LT - Left side (used to identify procedures performed on the left side of the
body)
The following bullets are some reporting notes and tips for submitting
In the event that more than two modifiers are required when reporting
important that the Q3 modifier is reported in the first modifier position. This
Services are to be reported under the name and HIC number of the
billing arrangement
• Note: Modifiers Q7, Q8, and Q9 are effective for dates of service on
services.
information.)
(CRNA) by an anesthesiologist.
coinsurance)
This modifier is only used by the ASC for identifying the facility charge. It
made for the technical component alone. Under those circumstances the
is used to indicate the course of treatment for radiation therapy has ended.
physician/non-physician.
with claims received on or after June 23, 1998, do not report the ZP
purchased, blocks 20 and 32 of the CMS 1500 claim form (or electronic
10. Diagnosis Code: Diagnosis code is used to indicate the health problem
that a patient have. The first of these codes is the ICD-9-CM diagnosis code
describing the principal diagnosis (i.e. the condition established after study
code (or codes) on each claim submitted for payment. The first of these
This field is printed in the 21st field of the CMS-1500 claim form.
oxygen volume. If only one service was performed the numerical 1 should
be entered.
service. In other words it is the total charge value of the claim. The billed
the respective claims / patient accounts or other accounts in the billing system.
Cash team receives the cash files (Check copy and EOB) and applies the payments
in the billing software against the appropriate patient account. During cash
to the Analysts.
according to the fee schedule. The insurance pays the cash through checks which
is deposited in the specified banks date-wise. Each check has its own unique
number and date on which the check was issued. The checks along with the claim
details are received by the Billing Office in U.S who in turn groups a certain
amount together and sends to the billing office here. The details which are
received with the checks are known as the EOB (Explanation of Benefits).
The Billing Office here receives the scanned documents as files. The received files
are then collected by the cash poster who gives the file reference numbers based
on the date on which the file was received. Then the cash poster matches the
checks with the EOB details. This process is termed as file sorting or Check
matching. Now the file had been sorted and the details are posted in the Software
Electronic Posting
posting the above said methods are carried on whereas in case of electronic
posting the amounts deposited in the bank gets transmitted electronically to the
billing office here. The transmitted details are known as Electronic File Transfer i.e.
EFT’s. This Eft’s are received by the cash poster with the insurance reference
number. Then the Cash poster retrieves the transmitted details and starts posting
the cash electronically. In this posting the amounts that are allotted to the claims
get identified by the software itself and the respective amounts are posted, for
Once the posting is over the amount posted in the software is tallied with the
amount received. Then a detailed report containing the claim and its posting
• Claim:
claim.
the claim in case of reference. Some insurance companies address the claim with
the help of the claim number. It can be of the combination of any numeric values
along with the alphabetical values. It is insurance specific and no general format is
• EOB:
the amount paid by the insurance, Co-pay / Co-insurance amount and write-off
amount. It also contains the patient name, patient address, patient account
number, SSN, insurance name, insurance address, insurance contact numbers and
it’s customer care numbers (if any). If insurance does not pay the claim then the
reason for which the claim was not paid i.e. the denial reason is also mentioned in
provided by the insurance for the claim. Some insurance like Medicare have their
For Example:-
amount of benefits paid or denied for services under the Medicare program.
• Billed amount:
In other words it is the total charge value of the claim. The billed amount for a
specific procedure code is based on the provider. It may vary from place to place.
• Allowed amount:
specific service. It is the maximum dollar amount assigned for a procedure based
on various pricing mechanisms. Allowed amounts are generally based on the rate
For Example:-
If the billed amount is $100.00 and the insurance allows $80.00 then the allowed
• Paid amount:
It is the amount which the insurance originally pays to the claim. It is the
may be either full or partial. i.e. Full allowed amount being paid or a certain
For Example:-
If the billed amount is $100.00 and the insurance allows $80.00 but the payment
amount is $60.00. Here $60.00 is the actual amount paid for the claim.
Formula: -
• Co-pay:
The fixed dollar amount that patient requires to pay as patient’s share each
time out of his pocket when a service is rendered. This is paid during the time of
the visit. Co-pay ranges from $5.00 to $25.00. Co-pay’s are usually associated
with the HMO plan. The Co-pay amount is usually specified in the insurance card
copy.
For Example:-
If the billed amount is $100.00 and the insurance allows @80%. The payment
Formula: -
• Deductible:
Deductible is the amount the patient has to pay for his health care
services, whereas only after the patient meets the deductible the health insurance
plan starts its coverage. The patient has to meet the Deductibles every year. It is
mostly patient responsibility and very rarely another payor pays this amount.
This is the number which is given by the operator to the claims posted in
order to keep track of the payment posted details. This is generally given in a
01.3651.123103 here the 01 refers to the serial number, 3651 refers to the
batch number and 123103 refer to the date and the year on which the file was
received by us.
• Offset:
excess payments and wrong payments are made. If insurance pays to a claim
more than the specified amount or pays incorrectly it asks for a refund or adjusts /
offsets the payment against the payment of another claim. This is called as Offset.
For example:-
Let the total billed amount of two claims is $100.00 each and the specified
payment for this is $80.00. The insurance pays $90.00 for the first claim. Here
$10.00 is paid in excess. Now while making payment for the second claim the
insurance pays $70.00 and sets $10.00 as offset. Now the insurance payment
• Refund:
This is the process of returning back the excess money paid by the
amount, insurance / patient request for a refund. The process of Refund is usually
For example:-
this is $80.00. The insurance pays $90.00 for the claim. Here $10.00 is paid in
excess. Now the insurance requests for a refund of $10.00 which will be done as
• Adjustment:
For Example:-
Let the billed amount of a claim be $100.00 and the paid amount is given as $70
adjusted.
off is usually done when the insurance payments are made. It is the balance
of what the insurance have allowed on a particular charge i.e. Total Billed
recovered at all.
For Example:-
payment amount is $80.00 then the remaining $20.00 is the write-off amount.
• Denial :
Denial is the technical term used for the non-payment of a claim by the
insurance. The insurance usually pays the claim if the details presented to them
are sufficient enough for processing. If there is any lack of information then the
insurance quotes a reason for which the claim is not considered for payment which
is known to be the denial reason. These reasons are found in the EOB. Some
insurance like Medicare follow a general set of denial codes which is uniform
across all the states. But some commercial insurance follow their own set of
reasons codes for the denials which will be clearly mentioned in the EOB.
For Example:-
If the claim has gone to the insurance without the patient date of birth then the
insurance will not pay the claim stating a denial reason code to it.
• Balance Billing:
approved by insurance. Once the claim payment had been made by the
primary insurance and if there is any balance pending for the claim then the
If the patient is enrolled with the secondary payor then the balance is
billed to it. Generally for secondary billing the claim must be submitted
for the claim. In secondary billing primary payor EOB is the most important
patient has any. This procedure is termed as Crossover which reduces the
If the patient is not enrolled with the secondary payor then the balance is
billed to the patient. Patient billing cannot be done at all the cases. For
certain cases we need the client’s approval for patient billing. Periodic
patient statements are sent to the patient in order to intimate the balance
• Capitation Payment
which the provider is paid a fixed amount for each person served no matter what
individual with a specific set of services over a set period of time, usually a month
or a year. It is a payment system where managed care plans pay the health care
providers a fixed amount to care for a patient over a given period. Providers are
not reimbursed for services that exceed the allotted amount. The rate may be
fixed for all members or it can be adjusted for the age and gender of the member.
plays a crucial role in identifying and resolving issues which helps to reduce or
clear receivables.
The purpose of claim analysis is to identify and resolve medical claims billing and
insurance claims and patient bills by insurers or patients as appropriate. The scope
of claim analysis is applicable to all health insurance claims and patient bills that
have not been fully and finally settled by liable party or parties comprising health
company. The main motive of this department is to collect money for all the
treatments taken by the patients in a timely fashion. Usually the turn around
period for the payment by the insurance company is 30 – 45 days. Once the limit
is exceeded AR department has to make an enquiry for the delay. There are
e) Correct details may not have been provided to the insurance companies.
f) Claims were sent correctly but Insurance Company may not have received
the claims.
g) The checks issued might have been sent to the wrong address.
h) The insurance company may delay the payments if they have a backlog and
they would inform us by a letter that they have received the claims and
department can gather & update lot of billing information which is required to
settle a claim. Account analyst uses various reports available in billing software to
The Medical billing software is capable of running reports that pull out claims that
are unpaid for greater than 30 days. These are called aging reports and these
reports show pending payments in slots such as 0 – 30 days, 31-60 days and 61-
90 days. Claims filed within the last 30 days will find themselves in the first slot
(0-30days). Claims that are more than 30 days but less than 60 days old will be
would be necessary to find out why the claims are yet to be paid and what needs
to be done to have these claims paid. The delay and denials will be corrected by
the billing office in coordination with the physician’s office and the insurance
carriers. The same applies when patient billing statements are sent out. The
patient is given 3-4 weeks to pay the bill and if the payment is not received with in
that time, the billing office will follow up with the patient
resolve the pending accounts at the earliest. Calling is a support media for A/R
outstanding for more than 40 days and for which no correspondence has been
obtained.
Insurance carriers
Hospitals
Physicians office
Patients
Insurance carriers
Calls are made to the insurance carrier to confirm on the eligibility of the insured,
the type of insurance the subscriber has with the respective insurance and/or the
Calls are made to the insurance carrier to confirm on the provider enrollment
details. In order to check whether the provider is participating with the insurance
3. Claim status
Calls are made to insurance company to enquire about the status of a claim that
has already been filed to them, but for which there has been no correspondence
Hospitals
Calls are made to the hospitals to check on the pre-authorization, pre-certification,
Physician’s office
Calls are made to the physician’s office/PCP office to obtain and confirm on the
Calls are made to the patient to confirm on the insurance policy details, to obtain
and confirm on the patient’s other insurance details or to inform the patient about
Calls are made to patients and insurance companies, hospitals, physician’s office
under the client’s name. Thus the carriers and patients would have no way of
knowing that they are being called from an outside firm, but rather the clients’ in
The accounts receivables would be managed under the client’s name, therefore
Calling – classification
Inbound:
Calls that the office receives from patients, insurance carriers etc is termed as
inbound.
Patients call the billing office to check on the payments and on clarifications
Insurance carriers call the billing office when a message is left for them to
call us back and/or for clarifications on claims that have been filed with
them.
Calls that our office makes to the insurance carriers, patients, hospitals, provider’s
enrollment details and/or to check the status of the claim that is filed.
Calls are made to the patient to follow-up on the payments, to confirm if the
statements sent have been received by them and also to check on their
authorization details.
Cld : Called.
TT : Talked to.
Dnd : Denied.
Pt : Patient.
Clm : Claim.
Diag : Diagnosis.
Ins : Insurance
Pd : Paid
Amt : Amount
Sample 1
Good morning, this is ……… calling from ………………. (name of the physicians office)
to check the status of the claim. (If the rep asks for the provider/ tax id #)…… The
Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name
(If the claim has been paid, ensure all the check points for a paid claim is verified
and confirmed.) Thank you for your kind assistance. Have a great day.
Good morning, this is ……… calling from ………………. (name of the physicians office)
to check the status of the claim. (if the rep asks for the provider/ tax id #)…… The
Dr’s provider/tax id# is …………. The patient’s ID# id ………………., the patients name
(If the claim has been denied, ensure all the check points for a denied claim are
Called Insurance…………. . TT …………….. . She said that the DOS ………….. for the
Claim processed on…………. The copay is…….. the co-insurance is ………. And the
patient responsibility is …………. The check was mailed out to ……………. (address)
The AR Process is completed only when the necessary action is taken after
the calls has been made and has the claim reprocessed and converts the pending
claims into receipts/cash. It has also to be noted that when ever a new update
the other departments so that the speed of the collection is increased and the
A As in Apple
B As in Boy
C As in California
D As in David
E As in Edward
F As in Frank
G As in Girl
H As in Henry
I As in Indiana
J As in Jack
K As in Kite
L As in Larry
M As in Mary
N As in Nancy
O As in Orange
P As in Peter
Q As in Queen
R As in Robert
S As in Sam
T As in Tom
U As in Umbrella
V As in Victory
W As in Whisky
X As in X ray
Y As in Yellow
Z (zee) As in Zebra
Based on the Age the claims are classified in to 5 different age groups.
• 0-30 days: Claims falling under 30 days from the date of first filing.
• 31-60 days: Claims greater than 30 days but less than or equal to 60 days
from the date of first filing.
• 61-90 days: Claims greater than 60 days but less than or equal to 90days
from the date of first filing.
• 91-120 days and: Claims greater than 90 days but less than or equal to 120
days from the date of first filing.
• 120 - 150 days: Claims greater than 120 days but less than or equal to 120
days from the date of first filing.
The analyst sees that all the claims are followed up and necessary actions are
taken and callbacks are set for further course of action.
The claims with highest billed amount are identified and the same is placed for
calling. And the necessary actions are taken as per the feedback from the night
caller.
The insurance company/carriers with very short span of time for timely filing is
identified and the claims pertaining to those carriers are given for calling on
priority and necessary actions are taken based on the feedback from the night
callers.
The insurance company may send denials alone in their own format to the
Providers to know the denial reason for which they denied the claims. Those
a) The Ledger print outs are given to the night callers for their convenience.
b) On the ledger print out the analyst writes in short the previous issues of the
claim and also notes down the points that is to be enquired with the carrier.
Callers with the help of the notes given by the analyst, calls the carrier and gets
the needed information from the callers.
Analyst: Pending Claims above 30days which is not followed-up is given for Status
call.
Caller: Gets the status from the carrier, May be
a) Payment details
b) The denial reason
c) Claim Not in system etc.,
a) Payment Details: The caller should get the following when he is asking for
the payment details.
Check #
Check Date
Check Amount
Pay to Address
Cashed detail
Insurance Verification
Analyst: There may be cases were the charge dept/analyst may require to know
the correctness of the Member id# or the Mailing address etc of the patient with
the carrier.
Caller: Gets the mailing address, confirms the id# and other information.
Based on the call information’s are checked and the corrective actions are taken.
Analyst: Asks the caller to check for the validity of the coverage with the carrier.
Caller: Calls the carrier, confirms the validity of the coverage, and gets the
effective date and the termination date wherever possible.
Analyst: Would have received the E.O.B wherein one of the line item is not
considered for payment, so the analyst asks the caller to check for the reason for
having not considered the line-item.
Caller: Gets the reason for the procedure code not being considered, say line-item
missed from being considered, denied for some reason, but the reason was not
specified in the E.O.B or the claim is sent for review and so the same will be
paid/denied in due course of time.
Based on the feedback the necessary action is taken, say a Callback date is set.
Analyst: Receives an E.O.B with a particular procedure code denied with the above
reason. Asks the caller to get the exact reason for the denial.
Caller: Calls the carrier and gets the exact reason-Reason being “The claim should
be submitted along with the additional documents/Medical Notes to process the
claim”.
Based on the feedback from the caller the analyst sends a mail or Spread Sheet to
the Clients office requesting for Medical Notes. Once after receiving the same
claim is re-filed along with the medical records to the carrier.
Claim Denied stating “Diagnosis inconsistent with the Procedure code billed”
Analyst: Based on the denial received the analyst first sends nail/Spread Sheet to
the coding department to re-code the charge sheet with the correct Diagnosis,
after completion the same is given to the caller to update the new diagnosis in
their (carrier) system by telephonic conversation.
Caller: If accepted by the Rep, the new diagnosis is updated in the carriers system
or else the rep, requests for resubmission of the claim.
Based on the call made either the claim is marked for call back or else it is re-filed
with the new diagnosis.
Analyst: If there is authorization # present in the system then, the analyst gives
the same to the caller and asks to check if the same is valid for the provider,
procedure code, Date of Service and the Diagnosis code billed.
Caller: Call the carrier for validity of the authorization#.
Analyst: The analyst asks the caller to enquire the rep, if the claim will be
processed with any additional information, if yes, what sought of additional
information is required.
Caller: Requests the rep to let them know what information is required in-order to
get the claims processed.
Based on the in-formation from the carrier the necessary action is taken.
Analyst: Claim is denied stating “Bundled Service” asks the caller to get the
information as to, with which procedure code this particular procedure code is
bundled”.
Caller: The caller gets the info of the bundled service from the insurance
representative.
If the caller is not able to get the same then the analyst gets the help of the
Compliance dept. checks for the Bundled service information and based on this the
analyst generates report for that particular procedure code and sends a mail to the
client’s office for approval of write off.
For Ex. 82948 is bundled with 99213, 99214 and 99215.Here we are to write off
the procedure code 82948 with the consent of the Dr. (or) the client office.
Analyst: Asks the caller to check why the particular procedure was not paid.
Caller: Gets feedback from the rep that the Procedure code is incorrect and so has
to be filed with the correct code.
Action: The analyst should update the claim in problem in the Coding SS asking
them to correct the same. Once the charge is corrected in the system the claim is
refiled to the carrier.
Analyst: Asks the caller for the Claims status (primary carrier of the pt).
Caller: Gets the feedback from the carrier as “Primary EOB required for processing
the claim”.
Action: The analyst has to first check if the patient has secondary insurance, if
yes, asks the caller to call the secondary ins to check if they are acting as primary
ins for this patient, if yes then the analyst sends a mail or updates the Charge SS
asking them to archive the primary coverage and refiles the claim to the correct
primary carrier.
If the call was for Secondary claim, then the analyst should attach the Primary
EOB with the secondary claim and sends the same to the carrier by mail.
Analyst: Asks the caller to check under whose plan the Procedure was denied as
Non covered service.
Caller: Gets the info from the rep as “Non covered under patients plan” or “non
covered under providers plan”.
a) Non covered under Patient’s plan: Here the Analyst updates the client SS in
order to confirm if the claim can be flipped to the patient.
b) Non covered under provider plan: Here the analyst updates the Client SS to
check if we can Write-off the amount.
The analyst should first check if few claims were transmitted to the carrier on the
same date. If yes, then should ask the caller to check with the carrier stating
“there were few claims submitted on the same date out of which there are some
claims paid and some Denied if so then how this claim cannot be in system, the
caller should also give the date of confirmation to the rep.
If this was the only claim submitted on that date then the claim has to be refiled.
Action: The call back should be set after 15 days, and on 15th day can ask the
caller to call back and check if the carrier has received the needed info from the
patient. If no again to set a call back after 15day, can wait for one month, if still
the carrier does not receive the info, then with the consent of the client the claim
can be flipped to the patient.
Analyst: Should check for the correctness of the POS, i.e. for consult the POS
should be 11, For Inpatient POS should be 21 and for Outpatient POS is 22.There
are different POS for different cases.
Callers: Callers can give the correct place of service if they have in their system to
reprocess the claim immediately.
Claim forwarded to pricing Aid, Pricing Review.
Analyst: To place a calling to check for the Mailing address, Fax number and the
Timely filing limit.
Callers: Callers should ask for the PAPR Mailing address, Ph# once they have been
informed that the claim has been forwarded to Pricing Aid Pricing Review.
Contractual Obligation, amount for which provider is financially liable. The patient
may not be billed for this amount
Analyst: Should send a mail or should update the Client SS to get write-off
approval.
Analyst: Should first check with the Manual if the denied procedure code is a
"Bundled service", if yes has to check with the compliance department for the
details and should update the client SS for Approval of write off giving them the
reason and referring them the Manuel etc. If the Procedure code is not "Bundled
service" then the analyst can place a call with the insurance to check if the claim
will be processed if submitted along with the necessary documents.
Callers: Callers should ask for the Primary Procedure to which the component code
has been included.
Analyst: The billed amount should be corrected and the claim should be filed
again. Medicare has the Maximum Billed beyond which it is fraud. The Procedure
codes billed with a Billed amount more than their maximum billed amount will be
denied.
Analyst: The analyst after getting approval from the client will bill the patient, and
after getting the copy of the pre-existing condition certificate and medical
documents the claim will be submitted to the carrier.
Callers: After the submission of Claim with the Pre-existing condition certificate
from the Patient along with the medical documents, callers can call and give the
date of submission and the ref# which was assigned by the Carrier to the patient.
Claim denied for Date of Injury, First Diagnosis Used and for Pre-existing
conditions
Analyst: The analyst requests for the DOI, first Diagnosis code used and the Pre-
existing condition from the Client, after getting the same the claim is sent for
reprocessing. As this is a paper claim the call back will be placed after 45 days.
Callers: After the submission of Claim with the Pre-existing condition certificate
from the Patient along with the medical documents, callers can call and give the
date of submission and the ref# which was assigned by the Carrier to the patient.
Analyst: Write-off will be taken by the Analysts after getting a one time approval
from the client.
Analyst: The claim will be submitted as a itemized bill, i.e. the entries in the
claim will be date vice and not a clubbed entry for different date of service, and
along with the copy of the insurance card copy.
Callers: After the 30 days from the date of submission, the caller has to call
and verify the status of the claims.
Analyst: Should check if there is any other alternate procedure code existing for
the billed procedure code and yes then the same is informed to the charge dept.
and the claims with this deleted(from the cpt manual) procedure code is reentered
with the alternate procedure after which the claims are resubmitted.
Callers: Callers has to ask whether there is an alternative new procedure code for
this procedure code with regards to the services rendered.
Analyst: Should file the claims to this Third party as per the information received
from the carrier. Once after getting the phone number of the TPA from the carrier
a call is made to the TPA. The Fax # and other details are obtained for future calls.
Callers: Caller has to call TPA and get the Pricing sheet through fax and place it on
the Analyst bay.
Confirm that Hospice Patient did not appoint the Rendering Doctor
Analyst: There may be cases where, 2 units of the same procedure code will not
be paid by the carrier, we can check if the 2nd unit will be paid if submitted along
with a modifier and medical documents supporting the need for the service.
Callers: Callers has to ask why the one unit of the service was not paid. Callers
have to ask whether this procedure code can be reprocessed if the additional
documents were submitted.
Analyst: Analyst has to first check with the client if we are capitated with the
particular carrier. The Rooster report is obtained from the carrier; this contains the
details of the claims under capitation. Based on this a capitated adjusted is raised
by the analyst to the cash posters.
Callers: Callers has to get the list of Procedure codes which are under the
capitation and Fee for Services.
Analyst: When a claim is denied for want of Surgical code, we are to check the Cpt
manuals and should take the corresponding 4digit surgical code and the same
should be filed with the same to the carrier.
Callers: Nil
Based on calls the remarks column is updated and after taking necessary actions
the issues column is updated segregating the feedbacks under various heads.
Callbacks are set for further action.
Action:
• If the secondary carrier says yes, then the claim is sent to the secondary.
Denial from the primary carrier needs to be attached if we have crossed the
timely filing limit of the secondary carrier. This will ensure that the claim will
be processed. Otherwise the claim may be denied by the secondary for
crossing the timely filing limit.
• If the secondary says no, then the patient has to be called for information
regarding his primary carrier.
• If the carrier says that they have paid the Doctor balance in error then a
refund has to be initiated and the procedure as stated in point a & b
above should be followed.
• If the carrier has denied the CRNA balance incorrectly then they will
reprocess the claim.
Action:
When the rejection states that the provider number is not valid for that particular
DOS, the issue should be forwarded to the provider enrollment team for retro
activation.
When the rejection does not specify anything but simply states invalid provider
number, then check if the number has been keyed in correctly in the system by
comparing the same with the original records available with the provider
enrollment department.
Action:
Check the charge sheet as to whether the rejection is due to wrong keying in
at the time of charge entry. If yes, correct the same and refile the claim. If not,
a) Check whether the carrier requires ASA or CPT code. If the Claim has gone with
incorrect code then the claim needs to be refiled with correct code. Forward this
issue to claims analyst who will check for errors of the same kind by running a
paid & outstanding report for that particular date of filing. This type of error occurs
due to lack of knowledge.
b) There is one more reason for getting this type of rejection. The carrier may not
be paying for some codes. So if point (a) is not applicable, this may be the cause
for rejection. A work order can be issued for the insurance calling team. If the
carrier says that they do not pay for the procedure then the amount has to be
written off.
There are some exceptional cases where the primary may not be paying for one
code whereas the secondary may consider the same (ex) Medicare won’t pay for
dental procedures whereas a secondary, Commercial may pay for the same.
Check the charge sheet as to whether the rejection is due to wrong keying in at
the time of charge entry. If yes, correct the same and refile the claim. If no, it
may be because of incorrect Dx. It is also possible that the 4 or 5 digit Dx is used,
which the carrier may consider to be truncated
Action:
a) First check whether modifier has been entered at the time of charge entry. If
no, have the same entered and resubmit the claim.
b) If modifier has been entered but the carrier rejects the same
Action:
Pre-existing condition refers to the terms & conditions entered into between the
carrier and the patient / subscriber before the beginning of the contract. The
rejection will usually say that the claim is being denied due to the pre-existing
condition. It would not specify what exactly the condition is. So carrier needs to be
called to find out the pre-existing condition. Preexisting condition may be for
anything. (Ex.) A) There may be a condition that for the first $5000 worth of
medical expenses the patient should bear it himself and the carrier would start
paying for expenses after crossing that limit. If the patient has not yet exhausted
the threshold limit then the claim would be denied for the pre-existing condition.
B) There may be a condition that the carrier would not be paying for the same
diagnosis more than once in a year. If a same diagnosis code is used on two
occasions in the same year then the carrier will deny the claim submitted for the
second time stating ‘pre-existing condition.
As soon as you receive the denial, work order can be issued to Insurance calling.
Check with insurance on the preexisting condition.
Action:
Some carriers insist on obtaining prior authorization from them before the surgery.
This may be for certain specific procedures or may even be for all procedures. So
these are carrier specific and procedure specific. Please note that it is the
responsibility of the Surgeon (and not the patient) to obtain the authorization#
from the carrier. When you get a denial from the carrier for this reason, give work
order to surgeon calling and find out if the surgeon has been paid.
If the surgeon has been paid: It is unlikely that a surgeon would have got paid.
But if he has got payment, then call carrier and find out why they have denied the
anesthesiologist claim when the surgeon has been paid. They will either reprocess
the claim or request a refund from the surgeon.
If surgeon has not been paid: Take a write off. You cannot flip the balance to the
patient.
Action:
For anesthesia claims it is mandatory to have time printed on the claim. This rule
is not applicable for flat fee codes. But we have got quite few denials from the
carriers who wanted anesthesia time even for flat fee codes. So wherever
anesthesia time is available the same should be noted for claims with flat fee
codes.
There is one more reason for this denial. If there are more than 4 line items in a
balance then the anesthesia time would not get printed on the same claim form
but in another. The carrier will treat the two forms separately and deny one for
incomplete information and the other for want of anesthesia time. This should be
avoided. Whenever you find a denial for this reason take the HCFA(s), staple them
and send the same along with a covering letter.
Action:
a) Give a work order to insurance calling to find out if they have paid for the
surgeon’s claim. If they have paid for the same, then the same has to be pointed
out since they have processed the surgeon’s claim, why would they require
surgeon notes once again for processing the claims? This line of argument can be
pursued and the claim processed.
b) If the carrier has not (yet) paid for the surgeon’s claim, then the surgeon needs
to be called for a copy of the surgeon / operative notes. It should be noted that
surgeon notes is a confidential document (i.e.) the request should be
substantiated with valid reason.
c) MAC B Cases: MAC stands for Monitored Anesthesia care. Certain Medicare
(Texas, Ohio, Alabama etc.) requires ‘Medical Necessity’ report for processing MAC
category ‘B’ procedure codes. This report needs to be signed by the surgeon.
Whenever we receive charge sheets with MAC B procedure codes for MCR in
‘affected sites’ (states which require Medical Necessity letters) then the medical
necessity letter for the same should be obtained from the doctor’s office. Once it is
received claim should be resubmitted along with the letter.
Action: Every carrier has a filing limit within which you have to submit a claim.
This filing limit is calculated from the date of service and not from the filing date or
the date the claim is sent out. When a carrier rejects the claim for this reason
check whether the claim was submitted in the first instance with in the filing limit.
If yes, then the claim has to be appealed with proof of timely submission. The
proof that is accepted by carriers for timely submission is ‘c’ (carrier confirmation)
reports and rejected EOB’s. When no other proof is available send the patient
ledger copy as proof. Not many carriers accept patient ledger copies as sufficient
evidence for timely submission. But it is worth trying in absence of other
documents.
If no, find out why the claim was not submitted with in the filing limit. Even If the
provider has no identification number issued by the carrier, the normal practice is
to submit the claim to the carrier and get a denial so that the same will serve as a
proof of timely submission. So if you identify that the claim has not been
submitted at all in time highlight the issue immediately.
The tax id# on the claim form differs from what is in the carrier’s record.
The ‘pay-to-address on the claim form differs from carrier’s records.
Some carriers update the details about provider (like tax id#, pay-to-address)
every year. For this reason they will ask for the W9 forms. When W9 form is
requested for the above reasons, fill the same carefully and properly and send it to
the carrier. Always remember that W9 forms should not be sent to Medicare and
Medicaid. Certain BCBS plans and other carriers accept W9 forms.
billing system using required parameters and identifies claims that are unpaid or
From the above report, the analyst selects claims that remain unpaid beyond 30-
45 days from the date of filing. The number of days depend on whether the claims
claims). The number of days depends on the average turnaround time for the
claims to get settled, i.e., from the date of filing of the claim to the date of receipt
The analyst then reviews patient account ledgers pertaining to the unpaid claims
to analyze why the claims are still outstanding. Analyst reviews patient ledger
remedial actions:
(a) If the analyst detects a charge entry, cash posting or claim submission error,
he/she informs the concerned department. The error is corrected and claim
resubmitted, if necessary.
(b) If the claim has been prepared and submitted correctly according to known
rules and guidelines, and the usual turnaround time has passed, the analyst
note is also made to AR caller indicating the type of information that needs to
(c) When claims are underpaid or denied, the analyst establishes the reasons for
(d) When claims are denied due to lack of documentation or additional information,
the analyst requests for such additional documentation from the provider or
billing office, and follows up with the insurance through the AR callers.
from the provider office. The analyst will have to follow the appeals process
and if there is a telephonic appeal facility, analyst should explore the same to
appeal. A copy of the patient ledger and copies of the relevant EOB should be
If the claim has been prepared and submitted correctly as per insurance
requirements, and usual turnaround time has passed, call needs to be placed with
Analyst or AR Caller obtains the required information from the insurance company
and documents the results of the call in the patient notes section of patient
Examples of the kind of situations that the analyst may come across and the
the insurance representatives the claim is not in their system, meaning they
don’t have a record of the claim. The AR analyst may now check the claim
address and review transmission reports to find out if the claim failed to reach
the carrier due to a bad address or a transmission error. If the address in the
system is incorrect, the analyst first finds out the number of claims that have
been affected due to the wrong address. Or if there was a transmission error,
(b) Caller patient notes reveal that claims have been denied. Then analyst initiates
notes.
(c) The insurance carrier may state that the claim has been settled. In such cases,
the AR caller obtains the payment date and checks details from the carrier and
documents them in patient notes. The analyst follows up with the cash
department on whether such a payment has been received. If the check the
carrier says has been issued has not been received and posted within two
weeks from the day of payment, he/she may prepare a report (depending on
the policy established by the client) on such missing checks and sends it to the
client.
(d) An issue may need feedback from client for proper resolution. If so, the analyst
sends a report to the client detailing the issue and seeking clarifications.
Once issues or problems have been identified the AR analyst initiates action to resolve
depending on the nature of the issue. Complete resolution of an issue may require
Analysts issue forward’s request to the concerned departments for issue resolution.
Issues that require inputs or actions from the client are forwarded to the client. For
instance,
department.
initiated to the cash department, while charge entry errors are corrected by the
charge department.
Details of outstanding claim balances that the analyst considers uncollectible, and
which may thus have to be written-off, are forwarded to the client for decision
making. Details of outstanding claims, where collections efforts have fail due to non-
the client. Such accounts may be moved to a collection account. A collection agency
AR analysts uses the following tools, reports and documents to identify and
investigate issues that are affecting cash flow and preventing timely and accurate
following tools, source documents and resources are required for complete and
effective AR analysis:
• AR calling
2. Custom Reports
3. Financial Reports
The extent to which the above mentioned tools and resources are used will depend on
the account receivables situation in the accounts. The AR analyst measures the
success of collection efforts by computing the current and past AR and collection’s in
the specialty and account he/she is handling, comparing it against industry standards,
wherever available. The analyst investigates the reasons for any rise in AR or any fall
To perform the most basic assessment of A/R, the following three pieces of
• Monthly Charges
• Monthly Receipts
Monthly Charges
The charges for the month are the total amount of fees charged for patient
care from the first working day through the last working day of the month,
whether or not they have been paid. Charges for services that fall outside
regular medical care should not be included. If you have been asked to testify
as an expert witness and have just billed the defense attorney for $3,000, that
is a charge and will undoubtedly produce income to you or the practice, but it
should be considered outside income and for the purpose of analysis should
Monthly Receipts
the dollars collected for the medical care that was rendered. A receipt must
correlate with a charge that was entered for the current month or in a prior
month.
The third category of information needed to analyze a practice is the total A/R
at the end of the month: the total balance that is due to the practice on the
last day of the month for patient care. In reality, the total A/R should be the
amount of money that can actually be collected eventually. Some factors can
over inflate this figure, such as failure to write off balances that are
uncollectible. This could involve care for a homeless person who was not
a collection agency, the practice has classified these accounts as “bad debt”.
For the convenience of posting collection agency payments, many practices fail
to write off these balances or subtract them from the total A/R. To perform a
true analysis, it is essential that the A/R figure reflect the total money owed
Once a practice has obtained the total monthly charges and receipts and the
total A/R at the end of the month, it can begin assessing the state of it’s A/R.
There are three methods of assessing an A/R: days outstanding, A/R ratios,
Days Outstanding
Days outstanding, or the average number of days it takes for a typical charge
There are many ways to figure days outstanding. The simplest method is the
following,
1. Take the accounts receivable of the practice on the first day of the month.
2. Add to it the A/R of the practice on the last day of the month and divide by
two. This gives you an average of the A/R for the month.
3. Divide this figure by the month’s receipts and then multiply it by the
5/4/2010 Page 216 of 310 Healthcare Division
number of days in the month.
The resulting figure gives you the average number of days a receivable is
For example, the equation below shows a practice whose A/R on January 1st
was $95,000. On January 31st A/R was $105,00, and the receipts for the
below,
achieved only in a setting where accepting the payment at the time of service
management but is considered acceptable. The real danger zone, whether the
ratios indicate how total A/R relates to a practice’s payments and charges.
To find out how quickly your average account is being paid, simply do the
following: Take the total A/R on the last day of the month and divide it by the
total payments received during that month. This should produce a number
ranging from 2.5 to 4. If the number is 5 or more, you are looking at 150
days (5 X 30 days) from the time when a charge is entered on the books until
For example, if a practice has an A/R of $100,000 on January 31st and total
receipts for the month are $30,000, the ratio of A/R to payment is 3.3,
the practice’s charges. Simply divide the A/R at the end of a given month by
$100,000 / $25,000 = 4
This number should be fairly consistent from month to month if there is good
ratio. If the numbers vary dramatically, this may indicate that the practice is
practicing near a ski resort. In the winter the surgeon’s A/R to charges ratio
may by lower than it is in the summer, when there aren’t as many broken
bones. Of course the A/R to receipts ratio also would be affected. Again, any
The following are the duties and responsibilities of a charge entry person:
a) Be aware of all billing rules for his/ her specialty and updates himself/
b) Ensure that the daily targets of production required of him/ her are met
without with he/ she should not leave for the day unless there is nothing
left to enter.
c) Ensure 100% accuracy of data entered. For this purpose they should
take a patient face sheet/ charge summary and completely check the data
d) Ensure that proper folders are maintained and are in proper condition
and easily retrievable for the charges received and entered. These folders
maintained separately.
e) Forward the charge files for audit immediately after completion. He/ She
should also ensure that the files are returned by audit properly and
g) Ensure that all e-mails from either the client or from within the group or
from the call center should be attended to and replied on the same day.
h) Ensure that the pending list is reviewed every week and any items which
i) Ensure that any special reports required by the client or from the account
j) Ensure that all charge files are received in time without any delay or with
there any such delays, this should be properly recorded and notified to the
client. Also if files are not received for a particular DOS but received for
a) Be aware of all billing rules for his/ her specialty and updates himself/
b) Ensure that the daily targets of production required of him/ her are met
without with he/ she should not leave for the day unless there is nothing
left to post.
c) Ensure 100% accuracy of data entered. For this purpose they should
completely check the data entered with the checks and EOBs.
d) Ensure that proper folders are maintained and are in proper condition
and easily retrievable for the cash received and posted. These folders
maintained separately.
e) Forward the cash files for audit immediately after completion. He/ She
should also ensure that the files are returned by audit properly and
posting the cash files and the following are identified: Patient Not Found,
initiated and approved by the manager and forwarded to the client office
periodically.
do so, is done every month and any discrepancies notified to the client.
h) Ensure that small balances if any are written off promptly and
periodically.
i) Keep their eyes open of any changes in EOBs and notify the AR analyst
acted upon immediately. These are very vital information and need
j) Ensure that all cash deposit files are received in time without any delay
Madras). If there any such delays, this should be properly recorded and
notified to the client. Also if files are not received for a particular deposit
k) Ensure that any special reports required by the client or from the
A Regular Mail Person is one who takes care of regular mails i.e. entering
the regular mails into the system and taking action on each one of them.
functions. The following are the duties and responsibilities of a regular mail
a) Ensure that all the regular mails received are entered in the system the
same day.
c) Ensure that action on all regular mails received is taken on the same day
on which it is entered.
certain carriers are received in regular mails. These should be made note of
applies to all claims for that insurance carrier, should be applied to all
claims for that insurance carrier and action taken accordingly. This is called
rejections and along with the AR analyst find out why such rejections occur
guides the group by providing lot of inputs in the form of rules and other
keeps it in control and ensures the billing office meets its objective. The
should
a) Be aware of all the billing rules for his/ her specialty and updates
b) Sets realistic collection targets every month for his/ her specialty.
month.
d) Ensure that proper rules are set such that clean claims go in the first
e) Coordinate with the charge and cash person to ensure that rules are
followed.
g) Ensure that adequate and quality work-orders are given to the night
i) Ensure that all denials received have been acted upon and global rules,
j) Ensure that overall AR days for the account meet industry standards is
n) Constantly keep track of electronic and paper claims and keep his/ her
eyes open for any major rejections and ensure that all electronic rejections
o) Keep his/ her eyes open for EOBs where the pay-to address is different
electronically.
q) Ensure that any special reports required by the client or from the
All providers, including nephrologists and oncologists, billing with the CMS-1500
must provide specific information about the patient, the patient's insurance, and
about themselves as service providers. The service provided is described by
revenue codes, revenue code descriptions, and HCPC. The number of services
rendered and the charge for these services depends on the facility's charge
master.
Providers billing with the UB-92 must supply specific information about the
patient, the patient's insurance, and about themselves as service providers. The
service provided is described by revenue codes, revenue code descriptions, and
HCPC. The number of services rendered and the charge for these services depends
on the facility's charge master.
The following table lists instructions for completing a UB-92 form. Bill fields are
also known as locator or location codes.
Locator or
Location Instruction
Code
2 Leave blank.
Enter the Patient Control Number, which is not required by Medicare but can
3
be used by providers for internal patient identification.
Enter the patient's full mailing address (including street name, city, state,
13
and ZIP code).
15 Enter the patient's sex ("M" for male or "F" for female).
16 Leave blank.
31 Leave blank.
Check with your intermediary to verify the format for admissions or other
breaks in service.
If the patient is within his or her 30-month coordination period, enter "33" in
32–36
one of these fields.
37 Leave blank.
38 Leave blank.
Enter the appropriate code and amount for certain services such as blood
39–41
and blood products.
Enter the appropriate Revenue Code. Revenue Codes are based on type of
service provided and billed for.
42
Insert appropriate Revenue Code.
Enter the Revenue Code narrative description to match the code in locator
42.
43
Insert appropriate description.
45 Leave blank.
Enter total charges. For hard copy claims enter "Revenue Code 001" to
47
designate the total charges for that claim.
48 Leave blank.
49 Leave blank.
59 Enter the patient's relationship to the insured: "A" "B" and "C."
63 Leave blank.
64 Leave blank.
65 Leave blank.
66 Leave blank.
83 Leave blank.
and plan for the implementation of the HIPAA requirements. The personnel must
HIPAA is the federal Health Insurance Portability and Accountability Act of 1996.
The primary goal of the law was to make it easier for people to keep
HIPAA is divided into five titles or sections. Each title addresses a unique
individuals to carry their health insurance from one job to another so that they do
not have a lapse in coverage. It also restricts health plans from requiring pre-
existing conditions on individuals who switch from one health plan to another.
Title II is called Administrative Simplification and it will have the greatest impact
+ Reduce the cost of health care by standardizing the way the industry
communicates information.
transactions, national code sets, and unique identifiers for providers, health plans,
The HIPAA electronic data requirements are meant to encourage the healthcare
manual to electronic systems in order to improve security, lower costs, and lower
appliances. However, if you take the toaster to Poland, it will only work if you use
a special converter. If you go to Sudan you will have to use still another
Transaction and Code Sets: HIPAA mandates the development and use of
standardized transactions for the electronic exchange of data. In addition, the use
numbered as follows:
The privacy rule will affect the day-to-day business operations of all
information.
has not been finalized; however, some of the security standards will be
claims. However, HIPAA may require changes to several aspects of paper billing,
+ Health Care Providers: Any provider of medical or other health services, who
bills or is paid for healthcare in the normal course of business. Health care
+ Health Plans: Includes individual or group plans that provide or pay the cost of
medical care and includes both the Medicare and Medicaid programs
• Ensuring patients can see and get copies of their records, and request
amendments;
their information.
information;
+ Media Controls:
The Billing office must develop formal, documented policies and procedures that
govern the receipt and removal of hardware and software (such as diskettes,
tapes, and computers). These policies are important to ensure that media
containing personal health information is protected and that those persons who
implementation features:
• Data backup
• Data storage
• Disposal
The Billing Company must document formal policies and procedures for limiting
physical access, while ensuring that properly authorized personnel can work
• Disaster recovery
• Maintenance records
• Accreditation
• Wrongful disclosures
• False pretenses
is registered under this Act he/she will be covered by the employer in case of any
accidents even after the employee retires or resigns the job. The coverage period
registers himself under this act it allows him/her to get the health insurance
This will come into place only if the patient is suffering from any disabilities.
Roster Billing: It is the process of billing multiple patients A/c's in one single
claim for the same TOS (Type of Service) rendered irrespective of the DOS (Date
of Service).
payment in which the provider is paid a fixed amount for each person served no
Euthanasia: This is nothing but Mercy Killing which means for E.g.: If someone is
in a Coma state the doctor takes the initiative of killing him rather than him being
come to a conclusion it was discussed that every individual would search the net
Medicare Benefits exhausted: When a person takes a treatment for more than
the prescribed limit (For E.g.: Mammogram can be taken only once in a year, if
taken for more than once in a year in that case Medicare would deny stating as
periodically (For E.g: After Jan 31st Feb 1st would be considered as 32 and it
continuous in the same manner for the coming days). This is used for creating
Reciprocal Billing: A reciprocal billing arrangement may exist when the patient’s
regular physician submits a claim for a covered visit which the regular physician
of "I’ll cover for you, and you cover for me," (on an occasional basis).
FROI: First report of Injury/illness, the employer has to send this report to
Worker's compensation.
primary medical care, dental or mental health providers and may be urban or rural
Shortage Area (HPSA) bonuses are a 10 percent incentive payment that is paid to
physicians only when their services are covered by Medicare and are performed
within the geographic boundaries of a HPSA area. The Incentive is paid only for
the professional service. Global services must be billed as two components with
separate charges for the professional component (billed with the HPSA modifier)
the services with the appropriate modifier for each procedure code:
HPSA, the physical location where the service(s) was rendered must be
entered if other than home in Item 32 on the CMS 1500 claim form.
HCFAC: Healthcare Fraud and Abuse Control Program, is under Office of Inspector
General (OIG) to control fraud and abuse that happening in health care.
regarding the fraud and abuse that happening in the health care industry.
Stop loss clause: The explanation for stop loss clause is "a limitation on the
Prosthetic devices: Prosthetic devices are appliances which replace all or part of
devices that restrict or eliminate motion of a weak or diseased part of the body.
Insurance will cover for the charges if it is covered under subscribers plan.
Under the formula set forth in section 1848(b) (1) of the Act, the
payment amount for each service paid for under the physician fee
value for the service; (2) a geographic adjustment factor (GAF) for each
factor (CF) for the service. The CF converts the relative values into
payment amounts.
For each physician fee schedule service, there are three relative values:
(1) An RVU for physician work; (2) an RVU for practice expense; and (3)
fee schedule area. The GPCI’s reflect the relative costs of practice
The general formula for calculating the Medicare fee schedule amount for
Catastrophic Limit: The maximum amount of charges that the patient has to pay
out-of -Pocket expenses during that year by setting a maximum amount will
Revenue Codes: This code is used in hospital billing and we have a column in
UB92 for printing this revenue code. It is a three-digit code and mainly it is used
in care. For ex: If a patient is treated in a intensive care unit for that care will
Hospice: Hospice is a special way of caring for people who are terminally ill, and
for their family. This care includes physical care and counseling. Hospice care is
age groups, including children, adults, and the elderly during their final stages of
life. The goal of hospice is to care for you and your family not to cure your illness.’
certify that the patient is terminally ill and probably have less than six
program.
The care that you get for your terminal illness must be from a hospice.
When you choose hospice care, Medicare will not pay for:
Referring & Ordering Physician: Referring physician is one who refers a patient
for the Professional services. Ordering physician is one who refers or orders the
HCBS: Home and Community based services waivers .It is basically an agency
aims at providing high quality, cost effective, consumer directed, home and
community based services and support for all persons with all types of disabilities.
Enrolled & Effective date: Enrolled date is the date on which the person gets
enrolled with the insurance. Effective date is the date from which the insurance is
by the states and the federal governments, which provides medical insurance
coverage for children's who are not covered by Medicaid funded program.
simple we can say a visit, which does not require overnight stay.
(e.g., mental health) are removed from coverage provided by an insurance plan,
Experimental Procedures: Any health care services that are determined by the
professionals in the US, as effective in treating the condition, illness or for which
insurance plans and medical groups offered by their employer and have the new
Balance Billing: The practice of charging full fees in excess of covered amounts,
full fees in excess of covered amounts, then billing the patient for that portion of
member (policy holders) information (i.e., Member ID, coverage period etc.)
diagnosis, patient care, and/or medical learning. Many rural area are finding uses
for telemedicine in providing oncology, home health, ER, radiology and psychiatry
among others. Medicaid and Medicare provide some limited reimbursement for
Defence Department. It gives medical care to the active duty members of the
military as well as retirees & their eligible dependents. The new name of Champus
is Tricare.
Dual Eligible: Persons who are entitled to Medicare (Part A and Part B) and also
be entitled to ESRD and then become entitled based on aged or disability. Or, an
develop ESRD.
during the 30 month co-ordination period (COB). The GHP (Group health plan)
acts as the primary in the COB period and at the completion of the 30-month COB
ASC (Ambulatory Surgical Center): A place other than Hospital that does
outpatient surgery. At an ASC you may stay for only a few hours or for one night.
the home.
ALJ: Administrative Law Judge-a person who hears the appeals of the denied
claims.
under 21 who are receiving Medical Benefits may receive health and dental
physicians, health departments, schools and some local health clinics. These
exams are available on a periodic schedule based on the age of the individual.
health care providers who are paid by the Federal government for reviewing the
determining when and what services a patient can access and receive
a patient's medical care. In order for a patient to receive a specialty care referral
or hospital admission, the PCP must preauthorize the visit, unless there is an
emergency. The term gatekeeper is also used in health care business to describe
anyone that makes the decision of where a patient will receive services.
those who have experienced serious illness injury or disease, but when do not
require intensive hospital services, the range of services considered as sub- acute.
It includes infusion therapy, respiratory care, cancer, strokes and AIDS care.
Private insurance companies will not provide coverage for workers where the risk
chances are very high. This uncovered area is known as Residual Market, where
NDC (Nation Drug Code): NDC is maintained by FDA (Food and Drug
"Universal Product Identifier" for the human drugs. The format is usually 5-4-1. 5-
Labeler code, 4 - Product code & last one for package code, 1 – Serial Number.
Security Act of 1935 to the each individual citizen in United States. This is a nine-
digit number (For example: 123 45 6789), First 3 Digit refers to Area Number.
Second 2 Digit refers to Group Number (01 to 99). The Last 4 Digit refers to Serial
provides financial benefits to people when they retired (age sixty-two and older)
age sixty-five may receive SSI if he or she meets certain financial eligibility
requirements.
the first box marked "PICA" on the top left corner of the HCFA 1500 claim forms.
This information will be used by proclaim to organize the payer date correctly in
the transaction. If the payer position flag is left blank, then the claim will be sent
marked as primary.
disabled people on Medicare pay their medical expenses. The Qualified Medicare
Social Services, helps how-income elderly or disabled people on Medicare pay their
• Specialist care without a referral: Open Access plans give you the
highest and there are no claim forms to submit when you visit in-
network providers.
Cigna offers three types of Open Access plans, each offering a different
situation. You may choose a PCP to coordinate your care and treatment,
network provider without a referral. Your costs are lower when you
group medical plan by another insurance company or medical plan to find out
established or negotiated rate per day rather than reimbursement of all hospital
charges as billed.
insurance plans and medical groups offered by their employer and have the new
Over the Counter Drug (OTC): A drug product that does not require a
Outlier Payments: Outlier payments are made to hospital to help offset some
of the financial losses associated with treating extremely high costs Medicare
cases.
based upon the cost of indemnity insurance coverage, rather than strict adherence
Orphan Drugs: Orphan drugs are those that are so designated under subsection
526 of Federal Food Drug and Cosmetic Act by granting orphan drug status. The
by CMS. Providers who have UPIN only can bill Medicare. The format is 6 digit (3
diagnostic lab and x-ray tests, mammograms etc., The purpose of offering
coverage for preventive care is to diagnose a problem early, when it is less costly
to treat.
Birthday Rule: The birthday rule related to the coordination of benefits and
determination of the primary payer when a child is covered by both parents health
insurance plans. This applies to non-divorced parents. The insurer of the parent
whose birthday month falls first in the year is the primary payers.
process and signed a contract with the health plan to deliver medical services to
members. The facility may be skilled nursing facility, hospital, pharmacy, and
nursing home.
care and allows patients who are not a danger to themselves or others to maintain
their everyday life without disruption after associated with a hospital stay. It
these 5-6 days a week and 6 hours per day, depending on patient’s condition.
method for sending and receiving files, documents, and data. Suppliers who utilize
traditional paper billing, plus they save money. If you are not an electronic biller,
• Electronic claims allow for faster payment because they can be paid
after 13 days while paper claims cannot be paid for at least 27 days.
provides the claim control number of claims that were accepted into the
no impact on the payment floor. Claim status inquiry allows the supplier
to log onto the system and electronically check the status of claims
one DMERC (however they still need to test communications with each
DMERCs.
imaging.
and children. Most pediatricians are members of a national body, such as the
One of the major challenges facing pediatricians is that the range of body sizes
(and weights) that they face in pediatrics is much greater than in adult medicine.
For example, a preterm neonate can be less than 2kg in weight while an obese
adolescent may be larger than the typical adult. Childhood is the period of
greatest growth, development and maturation of the various organ systems in the
body.
Another major difference between pediatrics and adult medicine is that children
are minors and, in most jurisdictions, cannot make decisions for themselves. The
treat the parents (and sometimes, the family), not just the child
PACE (Program of All-inclusive Care for Elderly): provides and coordinates all
needed preventive, primary, acute and long term care services so that older
certified by the state to need nursing home care and live in an area
the PACE interdisciplinary care team are paid for by the PACE
program.
• Are people who do not qualify for Medicaid eligible for PACE
enrollment?
Yes. If a person meets the income and assets limits to qualify for
Medicaid, the program pays for a portion of the monthly PACE premium.
Medicare pays for the rest. If a person does not qualify for Medicaid, he
eligibility.
A PACE participant is free to cancel the enroll from PACE and resume
time.