Health benefits which are allowed per a contract with a health insurance company
or a health benefit allowed by Medicare, Medicaid, Tricare or Workers
Compensation.
CPT – Current Procedural Terminology:
CPT is a list of procedure codes owned, copyrighted and developed by the
American Medical Association. A procedure is something that the doctor does to a
patient during a visit. For example, if you cut your finger and the doctor repairs
the cut, there is a procedure code to put on the claim form. The code is recognized
by coders, and insurance company claims software. Let’s look at the cut on the finger. To convert the repair to a CPT code, you need to know the length of the
wound, in centimeters so you can select the correct CPT code. For the purpose of
this example. You have a 1cm simple cut on your index finger. The repair of this
cut would be 12001. Every procedure performed MUST be supported by a correct
diagnosis code or ICD-9 code. The diagnosis or ICD-9 code for an unspecified
wound of the finger would be 883.0. Now, if you saw ICD-9 code 042 used with
CPT code 12001, you would be confused. That would be like saying the doctor
sutured the patient’s finger cut because the patient had AIDS. Therefore it doesn’t
make sense to suture a wound if there is no open wound diagnosis.
Deductible:
A deductible is a contractual amount that the patient is required to pay as an out of
pocket expense before the insurance company pays any claim sent to them. The
amount of deductible varies per patient and per insurance policy. Commercial
insurance and Medicare deductibles start in January of each year. Tricare
deductibles start in October each year. A patient may have a $1,000 deductible.
The patient is seen by the doctor on January 5th. The claim is for $250.00. The
insurance company allows $100 for the benefit or covered service. The patient
hasn’t met their deducible yet. The $100 is applied to the deductible. Now the
patient has a $900 deductible to meet before the claim is paid by the insurance
company. The patient comes in each month for the next 9 months. The claim is
sent in September. The $100 is applied to the remaining deductible. If the patient
comes in the next month (October), the deducible has been satisfied, so now a
check will be sent by the insurance company. Whether the patient actually pays
the deductible is between the provider and patient. The insurance company doesn’t
care if the patient doesn’t actually pay the deductible. All this means is that with a
$1,000 deductible, with $100 allowed for the visit it will take 10 visits before the
insurance company will release any money to pay the patient’s claim. Medicare
does care if the provider collects the deductible from the patient.
Dependents:
A Spouse and/or an unmarried child (whether natural, adopted or step) of an
insured person. When looking at the insurance card (other than Medicare) you
may see the policy number and at the end, you may see 01, 02, 03, 04 or another 2
digit number. These numbers have meaning, but could vary per insurance
company.
00: Insured or member (Some insurance companies may have 01 as the insured)
