Tuesday, 20 June 2017

Medicare Secondary Payer

MAC Medicare Administrative Contractor 
Medical Necessity A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic. 
Medi-Cal Medi-Cal is California’s Medicaid program. Provides health services for categorically eligible and low-income persons. www.medi-cal.ca.gov. 
Medicare A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). www.medicare.gov Medigap Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. 
Medigap is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference. 
Modifier In CPT coding, a two-digit add-on or five-digit number, representing the modifier, placed after the usual procedure code number. The two-digit modifier may be separated by a hyphen. 
MSP Medicare Secondary Payer

N
 N/C Non-Covered Charge -- Procedure is not covered by health plan.
 NPI National Identification Number – Standard unique 10-digit identifier assigned to health care providers by CMS. It replaces all previous identifiers. 

Palmetto GBA Effective September 2, 2008 Palmetto is the Medicare contractor for Jurisdiction 1 Part A/B. www.palmettogba.com/J1B 
Participating Provider A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan.
 PCP Primary Care Physician -- The doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them. 
POS Point of Service -- An insurance plan that allows a patient to choose doctors and hospitals without having to first get a referral from his/her primary care doctor. 
PPO Preferred Provider Organization -- A plan that contracts with independent providers at a discount for services. The physicians in a PPO are paid on a fee-for-service schedule that is discounted, usually about 10% to 20% below normal fees. A patient can use a physician outside of the PPO providers, but he or she will have to bear a bigger portion of the fee. 
Procedure Code CPT or HCPC code used to describe the service rendered. 
PTAN Provider Transaction Access Number -- Also known as your legacy Medicare number. 

RA Remittance Advice -- Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB. 
Referral Permission from your primary care doctor for you to see a specialist or get certain services. Responsible Party The person(s) responsible for paying a patient’s office or hospital bill, usually referred to as the guarantor 

Secondary Insurance Extra insurance that may pay some charges not paid by the primary insurance company. 
Skilled Nursing Facility Typically an institution for convalescence or a nursing home. The skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care. 
SOF Signature on File Supplemental Insurance An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell 
Supplemental Insurance for Medicare. 
Subscriber For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder. 

T
 TAR Treatment Authorization Request -- An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 
Tele Comm Support Internet software or hardware support with the staff of Tele Comm Computer Systems, Inc. 
Term Date The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage. 
TIN Tax Identification Number -- Also known as Employer Identification Number (EIN) 
TOS Type of Service -- A description of the category of the service preformed. 
TTY Teletypewriter for the hearing impaired 

Thursday, 15 June 2017

Glossary of Insurance and Medical Billing Terms

Deductible The amount an insured member must pay before the insurance company begins covering health care costs. 
DHS Department of Health Care Services for California www.dhcs.ca.gov 
Diagnosis Code ICD-9 code used to describe illness, injury or diseases 
DME Durable Medical Equipment 
DOS Dates of Service -- The date(s) when a patient was treated. 

E
 EDI Electronic Data Interchange
 EFT Electronic Funds Transfer -- A paperless computerized system enabling funds to be debited, credited, or transferred from the payer. 
EIN Employer Identification Number -- Also known as Tax Identification Number (TIN) 
EMR Electronic Medical Records -- Medical record in electronic format. 
EOB Explanation of Benefits -- Details regarding how your insurance company processed medical insurance claims, explains what portion of a claim was paid to the health care provider and what portion of the payment. 
EPSDT Early and Periodic Screening, Diagnosis, and Treatment -- A Medi-Cal program for individuals under the age of 21 who have full-scope Medi-Cal eligibility. This program allows for periodic screening to determine health care needs. 
ERA Electronic Remittance Advice -- Electronic file supplied by the payer to outline payment for submitted claims. Also known as an 835 file.

Fee for Service A method of payment for medical services rendered 
Fee Schedule A list of CPT codes and dollar amounts an insurance company will pay for a particular medical service
Formulary List of prescription drugs cost of which an insurance company will reimburse, or those that will provided free under a scheme. 

GPNet The EDI gateway to Palmetto GBA

 H
 HCPCS Healthcare Common Procedure Coding System -- 5-digit alphanumeric set of procedure codes based on the AMA CPT codes. A standardized medical coding system for describing the specific items and services provided in the delivery of health services. Also known as a Procedure Code. 
HIPAA Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information. 
HL7 Health Level Seven -- A data exchange protocol and interface for medical records and billing software that allows different systems to interoperate. 
HMO Health Maintenance Organization -- An insurance plan that pays for preventative and other medical services provided by a specific group of participating providers.

ICD-9 International Classification of Diseases -- A standard format to describe the illness, injury or diseases by using a three digit code. Also known as a Diagnosis Code. 
IPA Independent Practice Association -- An organization of physicians who are contracted with an HMO plan 
IVR Interactive Voice Response -- Palmetto GBA 24 hour telephone line, obtain Medicare Part B information, such as claim status, last 3 checks issues, and eligibility. 

Jurisdiction 1 California, Hawaii, Nevada, Guam, American Samoa, Northern Mariana Islands

Sunday, 11 June 2017

Glossary of Insurance and Medical Billing Terms


Accept Assignment Provider has agreed to accept the insurance company allowed amount as full payment for the covered services. 

Adjudication The final determination of the issues involving settlement of an insurance claim. 

Allowed Amount The amount of the billed charge the insurance company deems is payable. 

AMA American Medical Association www.ama-assn.org 

Ambulatory Care Any medical care delivered on an outpatient basis.

 Ancillary Services Services including laboratory, radiology, home health and skilled nursing facilities 

Assignment of Benefits The patient or guardian signs the Assignment of Benefits form so that the medical provider will receive the insurance payment directly. 

Authorization Approval from insurance company is required for patient to receive services. Prior Authorization may be necessary before hospital admission, or before care is given by non-HMO providers. 


Beneficiary Person covered by health insurance or Medicare benefits. 

Capitation A payment methodology in which the physician is paid a set dollar amount determined by per member per month calculation to deliver medical services to a specified group of people.

 CCS California Children Services -- A state program for children with certain diseases or health problems. 

CHDP Child Health and Disability Prevention Program -- A preventive program that delivers periodic health assessments and services to low income children and youth in California. 

Claim Response Report Palmetto GBA’s GPNet Claim Acceptance Response Report. This report is available for download immediately after claims submission. Report includes total claims submitted, accepted or rejected with error messages. 

Clearinghouse A company that, for a fee, electronically receives batches of claims from providers or billing centers and retransmits the data electronically to the designated payers. There is a contractual financial relationship between the clearinghouse and the payer. 

CMS Centers for Medicare & Medicaid Services -- Formally known as HCFA, CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. 

CMS 1450 UB-04 Uniform Bill formally known as UB-92 used for Institutional billing 

CMS 1500 The standard claim form used by health plans on which to consider payment to the medical provider

 COB Coordination of Benefits -- The process to determine the obligation of payers when a patient is covered under 2 separate health care plans to avoid duplicate payments for a single service or procedure.

 COBRA Consolidated Omnibus Budget Reconciliation Act -- Health insurance coverage that you can purchase when you are no longer employed, or awaiting coverage from a new insurance plan to begin. 

Contractual Adjustment A part of the charge that the provider or hospital must write off (not charge the patient) because of billing agreements with the insurance company.

 Co-Pay The portion of a claim that a member must pay out-of-pocket.

 CPT Code Current Procedural Terminology -- A 5-digit code used for describing the specific items and services provided in the delivery of health services. Also known as a Procedure Code. 

Wednesday, 7 June 2017

medical billing and coding

Skilled Nursing Facility​ - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care. 

SOF​ - Signature on File.

Software As A Service (SAAS)​ - One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS. 

Specialist​ - Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some health care plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist. 

Subscriber​ - Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder. 

Superbill​ - One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms. 

Supplemental Insurance​ - Additional insurance policy that covers claims for deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare. 

TAR​ - Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 

Taxonomy Code​ - Specialty standard codes used to indicate a provider's specialty sometimes required to process a claim. 

Term Date​ - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible. 

Tertiary Insurance Claim​ - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover. 

Third Party Administrator (TPA)​ - An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group. 

TIN​ - Tax Identification Number. Also known as Employer Identification Number (EIN). 

TOP​ - Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan. 

TOS​ - Type of Service. Description of the category of service performed. 

TRICARE​ - This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS. 

UB04​ - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form. 

Unbundling​ - Submitting several CPT treatment codes when only one code is necessary. Untimely Submission​ - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied. 

Upcoding​ - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor. UPIN​ - Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number. 

Usual Customary & Reasonable(UCR)​ - The allowable coverage limits (fee schedule) determined by the patient's insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient. 

Utilization Limit​ - The limits that Medicare sets on how many times certain services can be provided within a year. The patient's claim can be denied if the services exceed this limit. 

Utilization Review (UR)​ - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures. V-Codes​ - ICD-9-CM coding classification to identify health care for reasons other than injury or illness. 

Workers Comp​ - Insurance claim that results from a work related injury or illness. 

Write-off​ - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms. 

Saturday, 3 June 2017

Medical billing basic terms

Practice Management Software​ - software used for the daily operations of a provider's office. Typically used for appointment scheduling and billing. 

Preauthorization​ - Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense. 

Pre-Certification​ - Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn't guarantee the benefits will be paid.

 Predetermination​ - Maximum payment insurance will pay towards surgery, consultation, or other medical care - determined before treatment. 

Pre-existing Condition (PEC)​ - A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months). 

Pre-existing Condition Exclusion​ - When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective. 

Premium​ - The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage. 

Primary Subscriber​ (Insured) - The person under whom the insurance policy is obtained. 

Privacy Rule​ - The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments. 

Provider​ - Physician or medical care facility (hospital) who provides health care services. 

PTAN​ - Provider Transaction Access Number. Also known as the legacy Medicare number. 

Referral​ - When one provider (usually a family doctor) refers a patient to another provider (typically a specialist). 

Remittance Advice (R/A)​ - A document supplied by the insurance payor with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits). 

Responsible Party​ - The person responsible for paying a patient's medical bill. Also referred to as the guarantor. 

Scrubbing​ - Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer. 

Self-Referral​ - When a patient sees a specialist without a primary physician referral.

Self Pay​ - Payment made at the time of service by the patient. 

Secondary Insurance Claim​ - claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage. 

Secondary Procedure​ - When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard​ - Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or complement to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI. 

Popular Posts