CMS – Centers for Medicare and Medicaid Services

CMS is a Federal Agency responsible for overseeing and regulating Medicare and Medicaid. CMS come under the jurisdiction of the Department of Health and Human Services. CMS is also the agency responsible for monitoring an approving the code sets (CPT and ICD-9) under HIPAA. Medicare HMOs come under the jurisdiction of the area CMS offices. Medicaid HMOs come under the jurisdiction of a State Medicaid agency. CMS used to be called HCFA, the Health Care Financing Administration.

CMS 1500: 

The CMS 1500 is the current HIPAA approved standard paper claim form submitted to insurance companies to have the outpatient health benefit or the contracted provider visit paid. The CMS 1500 form is designed by the National Uniform Claim Commission. Most insurance companies desire to have the CMS 1500 form sent to them in an electronic format. The fields or blocks on the form are the same regardless if on paper or done electronically. The CMS 1500 claim form instructions can be found here:

 http://www.nucc.org/images/stories/PDF/claim_form_manual_v3-0_7-07.pdf 

 Coding: 

The process of converting a medical procedure, a surgical procedure, a hospital inpatient stay or a doctor visit to a CPT code. The medical diagnosis is converted to an ICD-9 code. Some supplies are converted to HCPCS Codes. The purpose of coding is to document the reason for the visit or service and what was done during that visit so that the insurance company’s computers can quickly recognize the coded numbers and process the claim for payment.

Co-Insurance: 

Co-insurance refers to an amount that a patient or insured person is contractually required to pay for medical care, after a deductible has been applied. In some health care plans, co-insurance is called "co-payment." Co-insurance is often specified by a percentage. For example, with some patient contracts, the patient or member’s coinsurance may require them to pay a percent toward the charges for a service and the employer or insurance company pays a higher percent. A good example is with Medicare. Medicare pays 80% of their allowed amount. The patient must pay an annual deductible plus 20% of the allowable. This 20% is called co-insurance. You can see this on the Medicare EOB or remittance as COINS. Co-insurance is separate from a deductible.

Contracted Provider: 

Also called a Par or Network provider. This is a physician, hospital or other medical care provider such as an Advanced Registered Nurse Practitioner (ARNP) or Physician’s Assistant (PA) that has agreed to be contracted with the patient’s health insurance company. This contract is a legal and binding document. The provider should have any contract reviewed by an experienced attorney before the signing of the contract. The contracted provider has agreed to send claims for the patient, be paid at an amount that is less than the provider’s usual and customary charges. For example, for an office visit, the provider may usually charge $125. The provider contracted to be paid $120% of the Medicare allowable fee. Medicare may allow $100 for the service, so the provider agreed to be paid $120 rather than $125. Very few insurance companies will allow close to 100% of the Medicare allowable. Most want to reimburse less than the Medicare allowable.