MEDICAL BILLING ; ical Bill It is the process of sending the Claim forms (CMS 1500 foam) to the Insurance company on behalf of the provider office: EOBEE ion Of Beniti The statement of response which we received from the insurance company after submit aclaim ERA (Electronic Remitance Advice) Itis a electonic format of EOB. DENIAL Itis a statement received from insurance company stating that they are not going to pay the claim and the statement is called denial. OR Itis the information mentioned in denied claim EOB. SPTCODE (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 24DREFERENCE BOOK Healthcare Common Procedure Coding System(HCPCS). Itis the. codes which specifies range for a speciality of provider CPT Code Ranges and Values Office Visit : 99201 - 99499 EM (Evaluation and management service): Anesthesia : 00100 - 01999 Surgery: 10000-69990 Radiology: 70000-79999 — (xray,scanning) Pathology & laboratory : 80000 - 89398 To check up medicine: 90281 - 99099 DIAGNOSIS CODE OR DX CODE The disease or illness of the patient is converted in to alpha numeric code is called “DIAGNOSIS CODE " it's range is 7 digit. (OR) IT REPRESENTS PATIENT DISEASE REFERENCE BOOK ICD 10CM (International classification of disease of 10th revision clinical modification). Itis effective from october 2015 before that ICDICM. DOS (Date of Sevice } Itis the date when the treatment was taken by patient . DOS MENTIONED IN CMS 15000 - Block 244REVENUE 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 + Patient + Registration + Encounter (Facing) * Demo Entry (Demo Sheets) + Medical Transcription (Voice Files) + Coding Charge Posting Or CDM (Charge Discription Master) + Payment Posting/Correspondence + Account Receivables + Collections MODIFIER: Itis alpha numeric code that gives extra meaning to the cpt code. BLOCK NO INCMS1500FORM -BLOCKNO24D What are the modifiers you used in your previous office or tell me some modifiers what you know ? ANS . We have used modifiers 26 - Itrepresents physician services TC — It represents technical component service LT ~ It represents service done for left side organ of bodyRT __- Itrepresent service done for Right side organ of body 50 — Bilateral services (Both sides organ of the body) 59- _ Ititis distinct service (used for 0 to 8 starting cpt codes) 26 - It itis distinct service (used for 9 series opt codes) 76 - Itrepresents represents same service done twice by same provider 7 - Itrepresents same service done twice by differenet provider Social Security Number (SSN) Itis a nine digit unique number issued to US citizens (permanent residents and temporary working residents.) Formatis 854- 46-7896 Pui Care Physician (PCP 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 jon erie seein Itis 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 TAXID Tax payer identification number (TIN) Itis 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 Itis the total amount charged for a claim service. BILLED AMOUNT IN CMS 1500 FORM = -- BLOCK NO 28 EEE SCHEDULEItis 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 Itis the amount paid to the provider by insurance. Patient R ai Itis the amount patient has to pay. Itis 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 Itis the initial amount paid to the provider before taking the service by patient Go Insurance Itis patient responsibility that patient has to pay if there is no secondary insurance. INSURANCE Primary Insurance Itis the insurance that is first responsible for making payments to the providers. Secondary Insurance Itis the insurance that is second responsible for making payments to the provider after the primary insurance. Tent Itis the insurance responsible for making the payments after secondary insurance. p> oniinaie Bench Patient has to decide who is primary and who is secondary before taking policy Allowed amount = paid amount + patient responsibilityPaid amount = allowed amount - patient responsibility Medicare It provides health care benefits for the people who are above age 65, who is physically handicapped people and who is suffering from (ESRD) End Stage Renal Disease. What are the plans involved in MEDICARE They are four types of plan in Medicare they are Medicare Part A Hospital coverage or It will cover inpatient Medicare Part B Physician services or Outpatient Medicare Part C : Medicare advantage plan (instead of Medicare other commercial insurances will pay) Medicare Part D Medicines or Drugs Medicare cross over claim The automatic transfer of a claim from primary medicare to the patient's secondary payer is known as medicare crossover (or) piggyback claims. Medigap Policy Medigap policy is also known as “Medicare Supplemental Plan’. + Itis always pay as secondary. + Itwill not pay for copay,co-insurance,deductible. 1 It will cover only one person. Railroad Medicare Itis Medicare program offered to retired railway employees (who are above 65). What is TFL for Medicare? TFL for Medicare 1 year MEDICARE PART B ANNUAL DEDUCTIBLE AMOUNT + $183.00 for 2017 & 2018 + $185.00 for 2019+ $198.00 for 2020 Medicare insurance id looks like Previously It Is a SSN# followed by suffix and now it is changed to Alpha numeric code. SSN#- 452 -30 -8619 Previous Medicare Id- 452308619A Present Medicare Id - MRXTSH99 IN WHAT CASES MEDICARE WILL PAY AS SECONDARY INSURANCE 1 Worker Compensation 2. Auto Insurance 3. Veterans Administration insurance Medicaid It will provides the health care benefits for the people who are below poverty line , pregnant women , people with disability. Medicaid spend down program (Or) Medicaid spend down cost (SDC) (Or) Share On Cost (SOC) Ifa person earnings totally spent on health care expenses he is eligible for medicaid spend down program. Siicare Itwill provides the health care benefits for Uniformed people and their families and retired employees. OR It is a regionally managed healthcare program for active duty & retired members of the uniformed services and there families. Shampva It will provides health care benefits for the spouse or child of a veteran who has been rated permanently and totally disabled for a service connected disabilityWork 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) Advance Beneficiary Notice Itis a notice sent to patient by provider when they believe this service will not cover by Medicare. PTAN Provider Transaction Access Number (PTAN) is a number issued to providers by Medicare, after enrolling with Medicare Commercial Insurance + UHC 1 877-842-3210 + AETNA 1 800-624-0756 + CIGNA 1 800-102-4464 + HUMANA 1 800-457-4708 + QUALCHOICE + CARE IMPROVEMENT + BLUE CROSS BLUE SHIELD Place of service Itis the place were service is rendered. Office visit - 14 In patient - 21Out patient -22 Emergency - 23 Ambulatory services -24 Skilled Nursing Facility- 34 POS MENTIONED IN CMS 1500 -- Block 248 Physical Address or Facility ~ it is place where provider office or facility is located FACILITY MENTIONED IN CMS 1500 -- BLOCK NO 32 Billing address it is place where EOB and cheques are sent by insurance company . POS MENTIONED IN CMS 1500 -Block 33 Clearing House Itis an Middle office between provider and insurance company. i. i mat ' ice? GATEWAY Reiection claims will be returned from Clearing office or insurance company is called rejection. PAYMENT WILL BE MADE IN THREE WAYS: 1 CHEQUE (2. EEI( Electronic fund transfer) It is way of transferring fund electrically. S.CREDIT CARD OR DEBIT CARD Charge Sheet or SuperBill Simply itis called medical records.It contain details of provider name, Date of service,disease and service details. HIPAA (Health insurance portability and accountability act) Itis Law implemented in 1996 by CMS. It is used to protects health records from third party. Appeal ‘A formal request sent to insurance company asking to reprocess the claim. Reprocess If insurance denied claim incorrectly we are asking to reverify the claim to get the payment itis called Reprocess 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 S.faxtt MEDICARE INSURANCE YOU WIL TRANSFER THE CLAIMS ELECTRONICALLY OR THRU MAILING ADDRESS? ANS: ELECTRONICALLYMANAGED CARE PLANS: + Managed care plans are mainly introduced to give better health benefits plan at affordable price and also to avoid patient's misuse of the policy. + Co-pay was introduced in managed care plan . + Network and PCP concept applicable. + Preventative service are covered + Authorization concept has been introduced. + Premium is less compared to indemnity/traditional plan. ‘TYPES OF MANAGED 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. AUTHORIZATION | YES yes | YES YES. HMO PLAN IT IS MANAGED CARE PLAN + IF WE TAKE HMO PLANPCP IS = COMPULSARY AND REFERAL COMPULSARY + NEED ELIGIBLE Is TO VISIT INNETWORK OUTNETWORK = NOT PROVIDER AND+ AUTH IS NEEDED FORALL HIGH DOLLAR AMOUNT CLAIM PPO PLAN IT IS MANAGED CARE PLAN + IF WE TAKE PPO PLAN PCP AND REFERAL IS NOT NEEDED . + INNETWORK AND OUTNETWORK PROVIDERS ELIGIBLE + AUTH IS NEEDED FORALL HIGH DOLLAR AMOUNT CLAIM IT IS MANAGED CARE PLAN + IF WE TAKE EPO PLANPCP IS COMPULSARY AND REFERAL |S COMPULSARY + NEED TO VISIT INNETWORK PROVIDER AND OUTNETWORK — NOT ELIGIBLE + AUTH IS NEEDED FORALL HIGH DOLLAR AMOUNT CLAIM POS PLAN IT IS MANAGED CARE PLAN + IF WE TAKE HMO PLANPCP IS = COMPULSARY AND REFERAL |S COMPULSARY + INNETWORK AND OUTNETWORK PROVIDERS ELIGIBLE + AUTH IS NEEDED FORALL HIGH DOLLAR AMOUNT CLAIMPIAN 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 | will type CORRECTED CLAIM in 19 TH BLOCK and | will submit to insurance company. W9 Form W9 form is used for updating the provider billing office address and provider related information with insurance. Date Of Birth According to date of birth rule for a child primary and secondary insurance is selected (when mother and father is having insurance) Mother 02/09/1992 Father 06/27/1990 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.30 FRESH CLAIM 30-60 1 ST FOLLOWUP 60-90 2"° FOLLOWUP 90-120 3°° FOLLOWUP 120+ FOLLOWUP,