MEDICAL BILLING

What is Medical Billing:

It is the process of sending the Claim forms (CMS form 1500) to the Insurance
company on behalf of the provider office.

HIPAA: (Health insurance portability and accountability act)

It is Law implemented in 1996 by CMS. It is used to protects health records from third
party.

EOB (Explanation of Benefits):

 The statement of response that we received from the insurance company

after submitting a claim.
 Insurance will send a response in the format of EOB OR ERA which consist
of payment or denied information.
 EOB will be available in the practice management system {PMS),
clearinghouse payer web portal and by calling the payer or insurance.

DENIAL

It is a statement received from the insurance company stating that they are not
going to pay the claim and the statement is called denial.

CPT CODE(OR) CURRENT PROCEDURAL TERMINOLOGY:

The treatment done by the provider to the patient is converted i n t o an alpha-

numeric code called "CPT CODE.” It represents provider service.

It Range is five digits.

CPT CODE MENTIONED IN CMS 1500 --- BLOCK NO 24 D

CPT Code Ranges and Values:

Office Visit: 99201- 99499

Anesthesia 00100 – 01999

Surgery 10000 - 69990

Radiology 70000 – 79999 (x-ray, scanning)

Pathology & Laboratory: 80000 - 89398

To check up on medicine: 90281- 99099

A previous company used CPT codes

Toxicology CPT code starts with eight codes or G codes.

Toxicology is a blood and urine test.

DIAGNOSIS CODE OR DX CODE:

The disease or illness of the patient is converted into an alphanumeric code called
"DIAGNOSIS CODE".

Its range is up to seven digits. It represents patient disease.

REFERENCE BOOK

The Interna tional Classification of Diseases is a globally used diagnostic tool,

for health management, clinical purposes, and medical billing.

ICD 10 CM (International classification of disease of 10 th revision clinical

modification). It is effective from October 2015 before that ICD9CM.

DOS (Date of Service) MENTIONED IN CMS 15000 - Block 24A

It is the date when the patient took the treatment.

MODIFIER:

It is alpha-numeric code that gives extra meaning to the CPT code.

IN CMS 1500 FORM - BLOCK NO 24 D

What are the modifiers you used in your previous office or tell me
modifiers what you know?

26 - It represents physician services.

TC - It represents technical component service.

LT - It represents service done for t h e left side organ of

t h e body.

RT - It represents service done for t h e Right-side organ

of the body.

59 - It is a distinct service. (Differentiate the service)

GW - The GW modifier indicates that the service rendered is unrelated to the

patient's terminal condition. All providers must submit this modifier when the
service(s) provided are unrelated to the patient's terminal condition.

Social Security Number (SSN):

It is a nine- d i g i t unique number issued to US citizens (permanent residents and

temporary working residents.) or it is an identic card number for US Citizens.

The format is 000-00-0000

Primary Care Physician (PCP):

PCP is the provider who provides initial care.

Referring provider:

The referring provider refers to the other special services or other providers.
IT IS MENTIONED IN CMS 1500-BLOCK NO 17

Render ng provider:

The provider who does the services or who gives the treatment to the patient.

RENDERING PROVIDER NPI NUMBER IN CMS 1500 - BLOCK NO 24J.

National Provider Identifier (NPI):

It is a 10-digit number given to every US provider by the US government.

It is a certified number for the US provider.

TAX I D:

Taxpayer identification number (TIN) It is a 9-digit unique number given to every

provider by the US government.

Used to track the revenue of the provider.

TAX ID NUMBER IN CMS 1500 FORM - BLOCK NO 25

BILLED AMOUNT OR CHARGED AMOUNT OR TOTAL AMOUNT:

It is the total amount charged for the claim service.

BILLED AMOUNT IN CMS 1500 FORM -- BLOCK NO 28

FEE SCHEDULE:

It is the document that gives the cost for each CPT code.

It consists of CPT codes which are payable or not payable according to the payer.
ALLOWED AMOUNT:

The maximum amount fixed by the insurance company for a CPT code is based on the
insurance fee schedule.

Paid Amount:

It is the amount paid to the provider by insurance.

Patient Responsibility:

It is the amount patient must pay.

It is Co-Insurance, Co-Pay, and Deductible.

Deductible:
The deductible is a fixed dollar amount that patients must pay that amount before
the insurance starts to pay. It is repeated every year. Every year has some deductible
amount. The patient paid that amount then insurance starts to pay. It’s a different
amount for a plan to plan. Like $0 to $1000. It's decided according to the patient’s
premium.

Patients must satisfy a certain amount which was fixed by the insurance company after
satisfying that amount only insurance will pay for his medical benefits.

Copay:

It is the initial amount paid to the provider before taking the service by the patient
Or

A copay is the smallest fixed amount. The patient must pay the provider each and every
visit.

Co-insurance:

It is the patient responsibility that the patient must pay if there is no secondary insurance.

Or

Co-insurance It's a percentage. Insurance pays some Percentage, then the patient
pays some Percentage. It's a portion or percentage of the amount the patient and the
insurance carrier will share.

Coordinate Benefit: (COB)

 The patient must decide and update to insurance and provider who is primary and
who is secondary before taking service.
 The health insurance plans handle the COB. The health plans use a framework to
figure out which plan pays first and that they don't pay more than 100% of the
medical bill combined.
 Sometimes two insurance plans work together to pay claims for the same person.
That process is called coordination of benefits. Insurance companies coordinate
benefits.

Timely filing Limit:

 Each and every insurance company has a period to receive the claim. It's
called TFL.
 TFL consider from date of service (DOS).
 Each and every insurance company have a different timely filing limit.
 Appeal the timely filing limit considered from the denial date (DND).
 POTFL proof of timely filing timing

Federal Insurance Names:

Medicare:

IT is Federal insurance (Government) It provides health care benefits for people who

are above the age 65 and who is suffering from long disease and who is physically

challenged.
There are four types of plans in Medicare they are

• Medicare Part A: hospital coverage or it will cover inpatient.

• Medicare Part B: Physician services or Outpatient.
• Medicare Part C: DME (Durable Medical Equipment Medicare advantage).
• Medicare Part D: Medicines and prescription drug

TFL for Medicare 1year from DOS

Enrollment (credentials)?

 Provider getting enrolled or contract with the payer (insurance) is called

enrollment

 Contracted provider is called as in network provider, contracted provider,

participating provider.

 Non contracted provider is called as out of network provider, non-contracted

provider, nonparticipating provider.

PTAN #

Provider Transaction Access Number (PTAN) is a number issued to providers by

Medicare, after enrolling with Medicare

CLIA #:

The Clinical Laboratory Improvement Amendments of 1988 (CUA) regulations include

federal standards applicable to all U.S. facilities or sites that test human specimens for
health assessment or to diagnose,
prevent, or treat disease. CDC, in partnership with CMS external icon and FDA
external icon, supports the CUA program and clinical
laboratory quality
Taxonomy #

A taxonomy code describes the Provider or Organization's type,

classification, and area of specialization. Box # 33B

In what cases Medicare will pay as secondary insurance?

1. Worker Compensation

2. Auto Insurance

3. Veterans Administration insurance

Medicaid:

It will provide the health care benefits for the people who are below poverty line. It

will cover health care benefits for poor people in US.

Its timely filing 1year from date of service.

Medicaid spend down program:

If a person earnings totally spent on health ca re expenses, he is eligible for

Medicaid spend down program.

Tricare:

It will provide the health care benefits for army people, families, and retired
employees.

Its timely filing limit is less than 1year from date of service {DOS). It depends upon
the state.

CHAMPVA:

It will provide health care benefits for the dependents of veterans or people

who are disabled in armed service.

Its timely filing limit is 2 years from date of service {DOS).

Work Compensation:

It will provide health care benefits for the employee who is subjected to illness or
accidents which happen during work time.

Its timely filing limit is 6 months from the date of service (DOS).

Place of service

It is the place where service is rendered,

 Office visit - 11

 In patient 21.

 Outpatient 22

 Emergency - 23

 Ambulatory services -24

 Skilled Nursing Facility- 31

 Independent laboratory 81

POS MENTIONED IN CMS 1500 -- Block 24B

PAYMENT WILL BE MADE IN THREE WAYS:

 CHECK

 EFT (Electronic fund transfer)

 CREDIT CARD

Charge Sheet or Superbill: Simply it is called medical records.

It contains details of provider name, Date of service, disease, and service details.

Contractual Adjustment: (Provider Write off) co45

It’s a simple adjustment or it’s a way of discount. It’s an agreement or contract

between provider and the payer, after the payment from the payer’s fess schedule

The balance amount will be adjusted off according to their contract.

Or
It is the contact between the patient and Insurance company. A Contractual p
Adjustment is a part of a patient's bill that a doctor or hospital must write-off (not
charge for) because of billing agreements with the insurance company. Adjustments,
or write-off's, are the dollars that are adjusted off a patient account for any reason.
The Contractual Adjustment is the most common type of adjustment.

Recoupment:

After the claim over paid or incorrectly paid the insurance will be taking back the
money.

Refund:

After the claim over paid or incorrectly paid we will be sending or returning their
money back.

Cross over claim:

when a primary insurance processed the claim and sending the remaining co-
insurance information to secondary insurance it is considered as cross over claim.

For example, claim is transferred to primary insurance Medicare and after paying
the claim by Medicare it will transfer the claim directly to secondary insurance.

Appeal:

A formal request sent to insurance company asking to reprocess the claim.:. Appeal
can be done over the fax or mail.

Reprocess:

If insurance denied claim incorrectly, we are asking to re verify the claim to get the
payment it is called Reprocess. Reprocess can be done over the call.
CMS: Centre for Medicare_ and Medicaid service.

HCFA: Health care financing administration. formerly known as CMS

Assignment of Benefits (AOB):

It is a legal agreement between patient and insurance company to release funds to

the provider.

AOB MENTIONED IN CMS 1500 --- BLOCK NO 13

Release of Information (ROI)

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 ² ways

1. electronic payer id:

It's an alpha numeric code which is used to send claim as electronically from
provider
PMS to payer PMS.

2. Mailing address:

Sending claim to insurance company as a hard copy.

CORRECTED CLAIM:

After making Necessary changes in claim form, it is considered as CORRECTED

CLAIM.

HOW WILL YOU SUBMIT CORRCTED CLAIM?

After making necessary changes I will type CORRECTED CLAIM in 22 BLOCKS,

and I will submit to insurance company.
W9 Form:

W9 form is used for updating the provider billing office address and provider related
information with insurance.

Skilled nursing facility:

Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor. A facility is responsible for payment to outside providers who
furnish these services/supplies/drugs to its patients/residence.

Or

Place where treatment given to who are suffering from long term disease.

HOSPICE:

It provides medical care and Treatment for persons who will be dying soon.

Skilled nursing facility (SNF) care - Medicare

Medicare-covered services in a skilled nursing facility include, but are 1t limited to:

• A semi-private room (a room you share with other patients)

• Meals

• Skilled nursing care

• Physical therapy (if needed to meet your health goal)

• Occupational therapy (if needed to meet your health goal)

AR AGING:

• Aging report is useful for catching charges that are going unpaid. It
has breakdown of aging bucket, and it is calculated from dos.

• An accounts receivable aging report, which offers a timeline of when a

 business can expect to receive payments.

AR AGING bucket

0- 30 FRESH CLAIM

30-60

60-90

90-120

120+

What are the ways to check the Claims status?

• EOB - PMS, payer web portal, clearing house or shared folder.

• Website (Payer web portal)
• By Calling the payer (Claim status department)

What are the ways to check the members eligibility?

• Copy of member id card

• Website (Payer web portal)
• By calling the payer (eligibility department)

Previously worked clearing house

(Zirmed or Wayster)

Commercial Insurance:

• UHC 1877-842-3210, its TFL is 90 days from DOS. corrected claim/appeal

TFL is 90 days from DND dos
• AETNA 1800-624-0756 TFL 180 days
• CIGNA 1800-102-4464 90 DAYS
• HUMANA 1800-457-4708 180
• BLUE CROSS BLUE SHIELD. It depends upon the state.
Molina Healthcare. Its TFL is 90 days from DOS
 Insurance name and websites:

 BCBS - Blue cross blue shield- Availity

 UHC - United healthcare - Optum
 Humana, Aetna - Navient
 Medicare TX - Novita’s
 Cigna - Cigna

How to identify a single patients DOS (Register #) it's a unique #

• Visit ID
• Accession #
• Acct #
• Invoice #

No response claims

• The claim which we haven't receive EOB or ERA from the insurance is
known as no claim, basically after submitting a claim there is no or what
happen to the claim.

MANAGED CARE PLANS:

• Managed care plans are a type of health insurance.

• They (Medicare and Medicaid)have contracts with health care providers and
medical facilities.

• It is used to reduce the overall cost of healthcare.

• Now it is used by private health benefits program.

They are four types of managed care plans they are

 • HMO (Health Maintenance Organization)

• PPO (Preferred Provider Organization)

• EPO (Exclusive Provider Organization)

• POS (Point Of Service)

For Medicare we can't sent corrected claim. We can do the necessary changes and
submit claims normally.

All the claims which and denied were converted into alphanumeric code is known as
Reason code, advice code remark code, and denial code.

PR - Patient responsibility denial code list

MCR - 835 Denial Code List

PR - Patient Responsibility - We could bill the patient for this denial however please
make sure that any other rejection reason not specified I n the EOB.

The same denial code can be adjusted as well as patient responsibility i ty. For
example, PR 45, We could bill the patient but for CO 45, i t's an adjustment and we
can’t bill the patient.
PR 1 Deductible Amount Member’s plan deductible applies to the allowable benefit
for the rendered service(s).

PR 2 Coinsurance Amount Member's plan coinsurance rate applied to allowable e

benefit for the rendered service(s).

PR 3 Co-payment Amount Copayment Member's plan copayment applied ed to the

allowable benefit for the rendered service(s).

NOTES

Rejected claim needs

• Claim rejected date

• Claim rejected reason

• Research done by the AR

• Fix I correction I action

Paid or denied claims need

• EOB, I call (insurance name, contact number, agent name)

• Receive date I process date

• Paid date or denied date

• Paid details or denied details

• Paid or denied claim #

• Action I correction I fix

• Call reference number