MEDICAL BILLING

Medical Billing :

It is the process of sending the Claim forms (CMS 1500 form) to the Insurance
company on behalf of the provider office(HOSPITAL)

EOB(Explanation Of Benifits) : The statement of response which we received

from the insurance company after submit a claim .

( OR )

IT IS THE STATEMENT RECEIVED FROM INSURANCE COMPANY

Electronic remittance advie

Denied -- insurance not paid

DENIAL : REASON

It is a reason received from insurance company stating that they are not going
to pay the claim and the reason is called denial.

OR

It is the information mentioned in denied claim EOB.

CPTCODE (OR) CURRENT PROCEDURAL TERMINOLOGY:

The treatment done by the provider to the patient is converted in to alpha

numeric code is called “CPTCODE”

Range is 5 digits.

( OR )

IT REPRESENTS PROVIDER SERVICE

CPT CODE MENETIONED IN CMS 1500 --- BLOCK NO 24 D

REFERENCE BOOK:

CPT Manual

It is the codes which specifies range for a speciality of provider

CPT Code Ranges and Values:

Office Visit : 99201 – 99499 -25 distinct

EM (Evaluation and management service)

Anesthesia : 00100 - 01999

Surgery : 10000 – 69990

Radiology : 70000 - 79999 (xray,scanning)

Pathology & laboratory : 80000 – 89398 59

To check up medicine : 90281 - 99099

DIAGNOSIS CODE OR DX CODE:

The disease or illness of the patient is converted in to alpha numeric code is

called “DIAGNOSIS CODE ” it’s range is 7 digit.

( OR )

IT REPRESENTS PATIENT DISEASE

REFERENCE BOOK

ICD 10CM (International classification of disease of 10th revision clinical

modification). It is effective from october 2015 before that ICD9CM.

DOS(Date of Sevice )

It is the date when the treatment was taken by patient .

DOS MENTIONED IN CMS 15000 - Block 24A

REVENUE CYCLE MANAGEMENT:

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

CAN U EXPLAIN RCM FOR ME OR CAN U PLEASE TELL ME THE STEPS INVOLVED
IN RCM?

ANS :It include process like

1 Retrival of files from clients system OR TAKING OF FILES FROM SOFTWARE

The next process is

2 Patient Demographics
And after this
3 Medical Coding - DIAGNOSIS CODE ,

- CPT CODE

4 Charge Entry
5 Transmission of claims or patient bills
6 Cash posting and denial documentation
7 AR follow up( ACCOUNT RECEIVABLE)
DESIGNATION -- AR Executive

MODIFIER –

It is alpha numeric code that gives extra meaning to the cpt code.

BLOCK NO OF

IN CMS 1500 FORM - BLOCK NO 24 D

What are the modifiers you used in your previous office or tell me some modifiers
what you know ?

ANS . We have used modifiers

26 - It represents physician services

24- unrelated service during post operative period

79- unrelated service during post operative period

TC - IT REPRESENTS TECHNICAL COMPONENT SERVICE(IT REPRESENTS

TECHNICIAN SERVICE)

LT - It represents service done for left side organ of body

RT - It represent service done for Right side organ of body

50 - it represents bilateral service(LT+RT =50)

59 - It represent it is distinct service

25 - It represent it is distinct service

76 - It represents same service done twice by same provider

77 - It represents same represents service done twice by differenet provider

Social Security Number (SSN) :

It is a nine digit unique number issued to US citizens (permanent residents and

temporary working residents.)

Format is 854- 46- 7896

Primary Care Physician (PCP) or Reffering Provider

PCP is the provider who provides initial care and refer the patient to the other
provider for special services.

BLOCK NO WHERE IT IS MENTIONED IN CMS 1500 - BLOCK NO 17

Rendering Provider:

The provider who gives actual treatment

National Provider Identifier(NPI):

It is a 10 digit number given for every US provider by US government.

RENDERING PROVIDER NPI NUMBER IN CMS 1500 - BLOCK NO 24J

REFERRING PROVIDER OR PCP NPI NUMBER IN CMS 1500- BLOCK NO 17B

TAX ID:

Tax payer identification number (TIN) It is a 9 digit unique number given for every
provider by US government.

TAX ID NUMBER IN CMS 1500 FORM - BLOCK NO 25

BiLLLED AMOUNT OR CHARGED AMOUNT: OR TOTAL AMOUNT

It is the total amount charged for a claim service.

BILLED AMOUNT IN CMS 1500 FORM -- BLOCK NO 28

FEE SCHEDULE:

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

ALLOWED AMOUNT :

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

Paid Amount :

It is the amount paid to the provider by insurance.

Patient Responsibility:

It is the amount patient has to pay.

Out of pocket maimum

It is Co- Insurance, Co-Pay, and Deductible.

Deductible:

Patient has to satisfy certain amount which was fixed by insurance company after
satisfying that amount only insurance will pay for his medical benefits.
Copay :

It is the initial amount paid to the provider before taking the service by patient

Co insurance:

It is patient respon sibility that patient has to pay if there is no secondary

insurance.

INSURANCE

Primary Insurance:

It is the insurance that is first responsible for making payments to the providers.

Secondary Insurance:

It is the insurance that is second responsible for making payments to the provider
after the primary insurance.

Teritiaryinsurance :

It is the insurance responsible for making the payments after secondary

insurance.

Co ordinate Benefit:

Before taking policy patient has to update his other ins details is called cob.

Patient has to decide who is primary and who is secondary before taking policy .

Allowed amount = paid amount + patient responsibility

Paid amount = allowed amount - patient responsibility

Federal Insurance Name or Government insurance

Medicare: It provides health care benefits for the people who are above age 65
and who is suffering from long term disease and who is physically handicapped.

what are the plans involved in MEDICARE

They are four types of plan in medicare they are

Medicare Part A: hospital coverage or It will cover inpatient

Medicare Part B : Physician sevices or Outpatient

Medicare Part C : Medicare Advantage Plan or Medicare HMO

Medicare Part D :Medicines

Medicare Advantage plan:

Instead of Medicare Private insurance will pay is called Medicare Advantage plan.

What is tfl for medicare?

TFL for Medicare 1 year

MEDICARE PART B ANNUAL DEDUCTIBLE AMOUNT?

Medicare Part B Annual Deductible amount $183.00 for 2018 and 2017

Medicare part b 2020-- $198

Medicare Part b 2021 -$203

Advance Beneficiary Notice ?

It is a notice sent to patient by provider when they belive service will not cover by
Medicare.

PTAN?
Provider Transaction Access Number (PTAN) is a number issued to
providers by Medicare, after enrolling with Medicare

Medicare insurance id looks like?

It Is a SSN# followed by suffix.

SSN# - 452 -30 -8619

Medicare id- 452308619A

IN WHAT CASES MEDICARE WILL PAY AS SECONDARY INSURANCE?

1 Worker Compensation

2. Auto Insurance

3. Veterans AdmiInstration insurance

LOCAL COVERAGE DETERMINATON:

It is a document implemented by medicare which contains information

which code is payale code and resonable

Medicaid:

It provides the health care benefits for the people who are below poverty line.

( OR)
It will cover health care benefits for poor people in US.

Medicaid spend down program:

If a person earnings totally spent on health care expenses he is eligibel for
medicaid spend down program.

Tricare

It will prov`ides the health care benefits for army people families and retired
employes.

OR

IT WILL COVER HEATH CARE BENEFITS FOR ARMY PEOPLE IN US.

Champva:

It will provides health care benefits for the dependents of veterans

or people who are disabled in armed service.

Work Compensation:

It will provide the health care benefits for the employee who subjected to illness
or accidents which happens during the work time.

OR

It will provide the health care benefits for the employee( who become ill or
injured in worked time)

Commercial Insurance:

 (United healthcare )UHC 1 877-842-3210 corrected claim/appeal TFL is 90

days from DND dos
 AETNA 1 800-624-0756 tfl 180 days
 CIGNA 1 800-102-4464 90 DAYS
 HUMANA 1 800-457-4708 180
 QUALCHOICE 120
 CARE IMPROVEMENT 120
 BLUE CROSS BLUE SHIELD
 Molina Healthcare
 AARP

Place of service -

sIt is the place were service is rendered.

Office visit – 11

Home -12

inpatient - 21

Out patient -22

Emergency - 23

Ambulatory services -24

Skilled Nursing Facility- 31

HOSPICE -34

Telemedicine – 2

POS MENTIONED IN CMS 1500 -- Block 24B

Physical Address or Facility –

it is place where provider office or facility is located.

POS MENTIONED IN CMS 1500 -- BLOCK NO 32

Billing address –

it is place where EOB and cheques are sent by insurance company .

POS MENTIONED IN CMS 1500 -Block 33

Clearing House:

It is an Middle office between provider and insurance company.

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

EMDEON , Gateway , Trizetto

Rejection:

claims will be returned from Clearing office or insurance company is called

rejection.

PAYMENT WILL BE MADE IN THREE WAYS:

1 CHEQUE

2. EFT( Electronic fund transfer)

It is way of transferring fund electrically.

3. CREDIT CARD

Charge Sheet or SuperBill:

Simply it is called medical records.

It contain details of provider name, Date of service,disease and service details.

Cross over claim:

when claim information is sent from a primary insurance to secondary insurance

it is considered as cross over claim.

For example claim is transferred to primary insurance medicare and after paying
the claim by medicare it will transfer the claim directly to secondary insurance.

HIPAA: (Health insurance portability and accountability act)

It is Law implemented in 1996 by CMS. It is used to protects health records from

third party.

PHI—PROTECTED HEALTH INFORMATION

Appeal:

A formal request sent to insurance company asking to reverify the claim.

Reprocess:

If insurance denied claim incorrectly we are asking to reverify the claim to get the
payment it is called Reprocess

DENIED – INSURANCE NOT PAID

DENIAL

CMS:

centre for medicare and Medicaid service.

HCFA:
Health care financing administration. formerly known as CMS

Assignment of Benefits (AOB): It is an legal agreement between patient and

insurance company to release funds to the provider.

AOB MENTIONED IN CMS 1500 --- BLOCK NO 13

Release of Information - It is agreement between patient and provider to release

patient health information to insurance company.

ROI MENTIONED IN CMS 1500 --- BLOCK NO 12

Claim will be sent in 3 ways

1.Electronic payor id

2.mailing address

3.fax#

MEDICARE INSURANCE YOU WIL TRANSFER THE CLAIMS ELECTRONICALLY OR

THRU MAILING ADDRESS?

ANS : ELECTRONICALLY

MANGED CARE PLANS:

They are four types of managed care plans theyare

1 HMO (Health Maintainence Organization)

2 PPO (Preferred Provider Organization)

3 EPO (Exclusive Provider Organization)

4 POS (Point Of Service)

HMO PPO EPO POS

PCP YES NO YES YES
REFERRAL YES NO YES YES
INNETWORK YES YES YES YES
OUTNETWORK NO YES NO YES
AUTHORIZATIO YES YES YES YES
N

HMO PLAN

IT IS MANAGED CARE PLAN

1. IF WE TAKE HMO PLAN PCP IS COMPULSARY AND REFERAL IS

COMPULSARY
2. NEED TO VISIT INNETWORK PROVIDER AND OUTNETWORK NOT ELIGIBLE
3. AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

PPO PLAN

IT IS MANAGED CARE PLAN

1. IF WE TAKE PPO PLAN PCP AND REFERAL IS NOT NEEDED .

2. INNETWORK AND OUTNETWORK PROVIDERS ELIGIBLE
3. AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

EPO PLAN

IT IS MANAGED CARE PLAN

1. IF WE TAKE EPO PLAN PCP IS COMPULSARY AND REFERAL IS COMPULSARY
2. NEED TO VISIT INNETWORK PROVIDER AND OUTNETWORK NOT ELIGIBLE
3. AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

POS PLAN

IT IS MANAGED CARE PLAN

1. IF WE TAKE POS PLAN PCP IS COMPULSARY AND REFERAL IS COMPULSARY

2. INNETWORK AND OUTNETWORK PROVIDERS ELIGIBLE

3. AUTH IS NEEDED FOR ALL HIGH DOLLAR AMOUNT CLAIM

PTAN:

IT IS THE NUMBER GIVEN FOR EVERY US PROVIDER AFTER REGISTERING WITH

MEDICARE INSURANE

CORRECTED CLAIM:

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

CLAIM.

HOW YOU WILL SUBMIT CORRCTED CLAIM?

After making necessary changes I will type CORRECTED CLAIM in 19 TH BLOCK

and I will submit to ins urance company.

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

Date Of Birth:

According to date of birth rule for a child primary and secondary insurance is
selected (when mother and father is having insurance)

Mother 02/09/1992 prim

Father 06/27/1990

In this case according to month decision is taken not year

Hence, Mother insurance is primary and father is secondary

Beneficiary OR Insured Person :

A person eligible for receiving benefits under insurance policy. He is also called as
subscriber.

HOSPICE:

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

AGING
Aging report is useful for catching charges that are going unpaid. It has breakdown
of aging bucket and it is calculated from dos.

1- 30 FRESH CLAIM

30-60 1 ST FOLLOWUP

60-90 2ND FOLLOWUP

90-120 3RD FOLLOWUP

120+ FOLLOWUP

New Patient :

A Patient visiting for the first time facility is called New patient

Code range – 99201 to 99205

Established Patient:

A patient visiting hospital for past three years is called established patient

Code range – 99211 to 99215