Medical
Billing
Federal
Insurance
- Medicare
- Medicaid
- Tricare
- RR Medicare (RR-Rail Road)
Medicare
Eligible
- People 65 Years above
- People Under 65 with certain Disabilities
- People of any aged with End-Stage Renal Disease ( ESRD) (Permanent Kidney Failure requiring or a Kidney transplant)
- FICA ( Federal Insurance Contribution Act) ( Continue 40 Quarters paid to Tax)
- Black hole Workers.
The
Different parts of Medicare
- Part A
- Part B
- Part C
- Part D
Part
A (Hospital Insurance)
Only
Covered with Hospital Services. ( Ex. Bed Charges & Equipment
charges)
Its
Cover Inpatient care in Hospital.
Its
cover Skilled Nursing facility, hospice and home health care.
Claims
billing to UB92 & UB04 forms.
Part
B (Medical Insurance)
Its
Covered with Doctors’ Services, hospital outpatient care and home
health care.
Its
cover some Preventive services to help maintain your health and to
keep certain illness from getting worse
Claims
Billing to HCFA & CMS1500 forms.
Part
C (PartA+PartB+PartD)
Medicare
Advantage plans (like an HMO or PPO) are health plans run by
Medicare-approved private insurance companies. Medicare Advantage
plans (also called Part C) include Part A, Part B and usually other
coverage like Medicare prescription drug coverage (Part D), sometimes
for an extra cost
Part
D ( Medicare prescription Drug Coverage)
Only
Covered with Drug Programme ( supply for Medicine) Ex: Sugar Patient.
Medicaid:
It’s
Covered with below Paverty people (or) Low income people. It’s
monthly month basic.
It’s
Called Spend down Charges for Copay
California
States Called Medicall
Tricare:
It’s
Coved with Army people.
Tricare
Two Types:
- CHAMPVA ( Civilian Health and Medical programme for Veteran affairs)
- CHAMPUS ( Civilian Health and Medical programme for Uniformed services)
RR
Medicare:
It’s
Covered with Railway Department, Transport Department & Highway’s
Department.
Worker’s
Compensation:
It’s
Covered with Work related injury and work relavent accident.
Auto
Accident:
It’s
Covered with Vehicle Accident.
Two
types of Auto Accident:
- No fault Auto Accident
- Non-No fault Auto Accident
Managed
Care Plans:
To
provide High quality service at low Cast.
1.HMO
(Health Maintanence Organization)
Patient
must goes to in-network Provider. PCP Must. (Low premiums, low
deductible, copay & coins). PCP means Primary care Physician.
2.PPO
( Preferred Provider Organization)
Patient
get treatment any provider. (Premium, deductible, copay & coins
High cost)
3.POS
(Point of Services)
It’s
companied with HMO+PPO
Patient
goes to any network provider (In or Out). PCP Must.
PAR
Provider: (Participating Provider)
Who
agrees and accept Insurance fees schedule and willing to contract
with Insurance company.
Non-PAR
Provider ( Non-Participating Provider)
Who
does not contract with any Insurance company. (no write off). Payment
fully paid to Patient.
Notes:
PAR
and NON-PAR provider only Contract with Insurance Company
Medical
Terminology
Allowed
Amount:
Insurance
Company fixed Maximum amount allowed each and every procedure code is
called Allowed amount.
Coins:
Portion
of the Allowed amount (or) Part of the Allowed amount
Copay:
It’s
fixed small doller amount pay’s to provider for every treatment
Deductible:
It
annum fee patient should to pay to insurance company before get
benefits starts.
Medicare
& Commercial insurance starts in January of each year
Tricare
insurance starts in October of each year
2009
PART-B annum Deductible amount - $135.00
2010
PART-B annum Deductible amount - $150.00
2011
PART-B annum Deductible Amount -$162.00
2012
PART-B annum Deductible Amount -$140.00
2013 PART-B annum Deductible Amount -$147.00
2014 PART-B annum Deductible Amount -$147.00
2013 PART-B annum Deductible Amount -$147.00
2014 PART-B annum Deductible Amount -$147.00
Authorization:
Two
types of Authorization
- Prior Authorization
- Retro Authorization
Prior
Authorization:
Provider
get approvel from the insurance before rendered the service. It’s
Called Prepaid service.
Retro
Authorization:
After
entered the service provider get approval from the insurance company.
It’s applicable for Emergency Care.
ABN:
(Advance Beneficiary Notice)
Expecelly
Medicare Policy Holders. Ex: Cosmetic Surgery.
It
Medicare denial “Medically not necessary then the medicare
beneficiary based amount to the provider.
Waiver
Liability:
Commercial
Policy Holders.
AOB:
Patient
assigned benefits to the provider behalf of the treatment.
COB:
Cordination
of Benefits
It’s
detail’s of Primary and secondary insurance.
Capitation:
- Fixed Capitation
- Rolling Capitation
- Fixed Capitation:
Provider
will be get fixed amount for every month
2. Rolling
Capitation:
Provider
will be get the amount for every patient.
SSN:
(Social Security Number)
This
Number all US Citizen Must. This Number Given by Social Security
Administrator. SSN 3-2-4 format. First 3digit-Area Code 2digit-Group
no. 4digit-Serial no.
Refund
or Take Back
Claim
wrongly Process and pay to the provider after the insurance company
find the amount and ask refund request from the provider.
Offset
or Recoupment amount
It
the provider not refund the amount in the insurance company bill be
adjusted on the next Claim.
Modifier:
- Information Modifier
- Reimpursment Modifier
1.Information
Modifier:
Does
not Varie the payment just indimate the insurance company which part
of the organ service was rendered (EX) LT, RT, Upper, Lower
2.Reimpursment
Modifier:
Varie
the payment who render the service patient (EX) PC, TC, 26
CMS
:
Centers
of Medicare and Medicaid Service
POS:
(Place of Service)
It’s
Indicate when the service was rendered. (EX) Hospital or Clinic
ROI:
(Release of Information)
Patient
accept agree to release their Medical Information
DX-Codes:
(Diagnosis Code) (ICD9 or ICD10 codes)
DX-Codes
means Diagnosis Code.
3-5
digit number. Ex: 123.45, Fever, Headage
HCPCS
level-1 codes
Cpt
Code means Procedure code. 5 digit number
Procedure
code include 6 types of Treatment.
- E/M (Evaluation Management) Visit. Starting with 99201-99499.
- Anesthesiology – Starting with 00100-01999, 99100-99140
- Surgery – Starting with 10021-69990
- Radiology (Including Nuclear Medicine and Diagnostic Ultrasound )(Ex: Exray, CT, MRI) – Starting with 70010-79999
- Pathalogy (Blood test, Urine test) – Starting with 80048-89356
- Medicine (except Anethesiology) (EKG (ECG), EMG) – Starting with 90281-99199, 99500-99602
HCPCS
Code:
Health
Care Financing Administration Common Procedure Coding System.
(pronounced "hick-picks"). Three level system of codes.
Level
I - American Medical Associations Current Procedural Terminology
(CPT) codes.
Level
II - The alphanumeric
codes which include mostly non-physician items or
services such as medical supplies, ambulatory services, prosthesis,
etc. These are items and services not covered by CPT (Level I)
procedures.
Level
III - Local codes used by state Medicaid organizations, Medicare
contractors,
and private insurers for specific areas or programs.
COBRA
:
The
term COBRA is an acronym for the Consolidated Omnibus Budget
Reconciliation Act of 1986—federal legislation that governs the
operation of group-sponsored health plans of businesses with twenty
or more employees. The COBRA Plan will offer continuing healthcare
coverage to you and your dependents if you leave your job.
You
will have to pay the entire COBRA premium on your own, however.
It’s
possible to extend COBRA’s Coverage for up to 18 months and a
surviving dependent can receive further extensions
Pre-Existing
Condition:
Patient
alredy suffered from Some diesease before enter the policy, Insurance
will not cover some duration for that disease, thats patient
responsible.... thats period called "Waiting Period". Once
the patient will complete their waiting period, insurance starts to
pay their services.
Ex:
Heart Disease, High blood pressure, Cancer and Asthma.
FECA-
Federal Employee's Contribution Act.
The
Federal Employees' Compensation Act (FECA) provides federal employees
injured in the performance of duty with workers' compensation
benefits, which include wage-loss benefits for total or partial
disability, monetary benefits for permanent loss of use of a schedule
member, medical benefits, and vocational rehabilitation. This Act
also provides survivor benefits to eligible dependents if the injury
causes the employee's death. The FECA is administered by the Office
of Workers' Compensation Programs (OWCP).
ABBRIVATION
ABN -
Advance Beneficiary Notice.
ATD -
Applied to Deductible
AWP -
Any willing Provider.
AOB -
Assignment of Provider
COB -
Coordination of Benefits
CMS -Centers
for Medicare and Medicaid services.- Designed by National Uniform
Claim Commission.
COBRA -
Consolidated Omnibus Budget
Reconcilation Act.
CHAMPVA-
Civilian Health and Medical program for Uniformed service
CHAMUS
– Civilian Health and Medical Program for Veteran affairs.
CPT -
Current Procedural Terminology.
DEERS -
Defense Enrollment Eligibility
Reporting System.
DHHS -
Department of Health and Human
Services.
DOS -
Date of Service.
DME -
Durable Medical Equipment.
EBSA -
Employee Bendfits Security
Administration.
EDI -
Electronic Data Interchange.
EGHP -
Employer Group Health Plan.
EIN -
Employer Identification Number.
ERISA -
Employee Retirement income
security Act.
ESRD -
End stage Renal Disease.
EOB -
Explanation of Benefits.
EPO -
Exclusive Provider Organization
EMC
- Electronic Media Claims
ERA
- Electronic Remittance advice
FFS -
Fee for Service.
GHP -
Group Health Plan.
HBMA -
Healthcare Billing Management
Association.
HCFA -
Health Care Financial
Administration.
HIC -
Health insurance Claim.
HCPCS -
Healthcare common procedure
coding system.
HMO -
Health Maintanance
Organization.
HIPAA -
Healthinsurance Portability and
Accountability Act.
ICD9CM-International
Classification of Disease 9 the revision of clinical modifier
IPA -
Individual Practice
Association.
IVR -
Interactive Voice response
LOP -
Letters of Protection.
MSA -Medical
Savings Account.
MSP -Medicare
Secondary Payer.
NonPar-
Non participating Provider.
NPI -
National Provider Identifier.
OIG -
Office of Inspector General.
OON -
Out of Network.
OOP -
Out of Pocket.
OWCP -
Office of Worker's Compensation
Program.
PCIP -
Primary Care Incentive Program
POS -
Point of Service.
POS -
Place of Service
PEC -
Pre-Existing Condition.
PHI -
Protected Health Information
PPO -
Preferred Provider
Organization.
PIP -
Personal Injury Protection.
PIN -
Provider Identification number.
PCP -
Primary Care Provider.
RA -
Remittance Advice.
RAN -
Referral Authorization Number.
RBRVS -
Resource Based Relative Value
Scale.
RRB -
Railroad Retirement Board.
SSA
- Social Security
Administration.
SNF -
Skilled Nursing Facility.
TPA -
Third Party Administrator.
UPIN -
Unique Physician Identification Number.
WC -
Worker's Compensation
ZIP -
Zonal Improvement Plan.
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