1. Group Coverage:- An Insurance plan by which a number of employees or other group member and their dependents are insure under a single policy or contract.
2. Premium:- Amount paid periodically to purchase Health insurance benefits. The amount paid or payable in advance often in monthly instalment for an insurance policy.
3. Subscriber:- The person who pay the premium to purchase an insurance policy. This person may ither pay the premium himself or as in most cases the person employer may pay the premium or a part of it on his behalf. It is very common in the US for an employer to purchase medical policy for his employees.
4. Dependent:- The spouse & children of the subscriber who are eligible for medical care under the insurance contract.
5. Effective date:- The date from which a person is eligible for medical benefit under his insurance.
6. Primary Insurance:- Insurance company who takes first responsibility for the patient bill. It would be pay a major portion of bill.
7. Secondary Insurance:- The secondary insurance will be responsible for any amount left unpaid after the primary insurance has paid.
8. Tertiary Insurance:- The tertiary insurance will be responsible for any amount left unpaid after the secondary insurance has paid.
9. Cob:- Coordination Of Benefits is a provision, If patient has more than one insurance policy then patient will decide which insurance comp pay the medical bill as primary & which pays a secondary.
10. Insurance Responsibility Form: The patient signs this form accepting responsibility for any charge not paid by his/her policy.
11. Assignment of Benefits: This form, signed by the patient, authorizes the doctor’s office to collect the patient’s benefits form his/her insurance company.
12. Release of Information: This form authorizes the physician to release the patient’s medical information to the billing office and the insurance company.
13. Promissory Note: This letter indicates that the patient has agreed to pay the physician for the treatment he/she has undergone.
14. Billed amount:- The amount charged by a provider as a compensation for his treatment.
15. Allowed amount:- The fix amount set by the insurance co for different treatment perform by the Doc.
16. Deductible:- Deductible is a specific amount set by the insurance co. which patient pay to the provider annually before the insurance company will pay the benefit.
17. Co-ins:- A specific % of the insurance allowed fee for each treatment. The secondary ins or the patient must pay the health care provider.
18. Co-pay:- Co-pay is a small dollar ($) amount ( Ex- $25, $35 ) which patient has to pay to the provider on every visit.
19. Write off:- The difference between a physician’s billed amount and the insurance company’s allowed amount will be written off after the insurance company pays the allowed amount. This is called write-off or dis-allowance.
20. EOB:- Explanation of benefit is a document which is send by the ins co to the doc office. It contains all the reimbursement details. (Payment detail/ Denial detail) Example – Allowed amount, Insurance payment, Co-pay, Co-ins & deductible
21. Benefits:- Amount payable by the ins co to the patient when patient suffer a loss.
22. Fee schedule:- A list of all medical treatment and their respected allowed amount is called a fee schedule.
23. ABN:- Advanced Beneficiary Notice it is a form which is signed by patient. In this form it is written that if Medicare denied making the payment of a particular claim then patient himself is responsible for making the payment to provider.
24. Crossover:- It is a process where Medicare automatically send its balance amount to the secondary ins company.
25. Capitation:- It is a kind of a Third party re-imbursement method where the provider gets one lump sum amount form the insurance company for a patient after that patient can go to the provider "N" number of time for "N" number of treatment.
26. Pre-Existing illness:- A health problem that patient is already having before purchasing the policy.
27. Waiting Period:- When patient purchase a policy insurance give a time duration for pre-existing illness. Ins says policy holder cannot avail the benefit of any pre-existing illness during this time. This time is called waiting period. It calculates form policy effective date.
28. Filing limit:- It is a time duration given by the insurance company on which we submit claim to the ins co. Filing limit is always calculate from date of service.
29. Appeal limit:- It is a time duration given by an insurance company on which we can submit our appeal if we think that the claim is being denied incorrectly. Appeal limit is calculated by date of denial.
30. Health Insurance Portability and Accountability Act (HIPAA):- A federal law intended to improve the availability and continuity of health insurance coverage.
31. Out of pocket expenses:- A medical bill or a part of it paid by a patient out of his own pocket because of non-payment of his insurance company is called out of pocket expenses. Example:- Deductible, Co-pay & Co-ins.
32. Out-Of-Network Benefits:- Covered services that are not provided, rendered or referred by your Primary Care Physician.
33. NPI#:- National Provider Identifier NPI is a unique 10 digit identification number for health care provider in US. Provider NPI is permanent and remain same with the provider regardless of job or location change.
34. PCP:- Primary care physician he’s the equivalent of a family doctor. Who when specialized treatment is required refer the patient to specialist for this reason he’s also called referring doc or gatekeeper?
35. Pre- Auth:- Certain services requires ins approval for which specialist need to call the insurance company and must take the approval then they will give an authorization number which is called prelaugh. To get auth# is the responsibility of provider
36. Referral number:- It is also issued by the insurance co to referring physician. Which referring physician (PCP) gives to the patient and patient hand it over to the specialist. To get referral number is patient responsibility
. 37. Medical Coding:- In medical coding we assigned codes to patient conditions (Disease) as well as treatment and coding done by coders.
38. ICD:- It stand for International Classification of Diseases 9th edition, which is the book published by WHO. ICD codes are standardized codes used to identify a patient’s condition. ICD minimum 3 & maximum 5 digit. It could be numeric or alphanumeric.
39. CPT:- CPT-4 It stand for “Current Procedure Terminology”. The "4" stands for the fourth edition of the coding system, currently in use. CPT-4 codes are the standardized codes to identify the treatment performed for a patient. CPT is standardized system of 5-digit code CPT Organization In the current CPT book, codes are grouped into six major sections: ASRPME A - Anesthesiology 00100 to 01999, 99100-99140 S - Surgery 10040 to 69990 R - Radiology 70010 to 79999 P - Pathology and Laboratory 80048 to 89399 M - Medicine 90281 to 99199 E - Evaluation and Management 99201 to 99499
40. V Code:- V code is used when patient not suffering on any disease. Example - Physical examination & Polio examination
41. E Code:- E code is used when patient is not suffering any disease but got injured due to some external cause. Example - Dog bite & Gunshot injury
42. Modifiers:- Modifiers are a 2-digit alphanumeric code that alters the procedure code (CPT) without changing it.
43. Fee For Service:- An arrangement under which patients pay doctors, hospital or other health-care providers for each service rendered.
44. HIPAA:- The Health Insurance Portability and Accountability Act of 1996 (HIPAA; enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996. To protect patient personal or diseases related information.
45. Participating Provider: - A Participating Provider is one who accepts the payment of the insurance company’s allowed amount as full payment, for any of the insurance company’s beneficiaries regardless of how much he billed for his services.
46. Non Participating: - A Non-Participating Provider is one who has not agreed to accept the carrier determined, allowed rate as payment in full for covered services performed and, therefore, expects to be paid the full amount of the fees charged for the services performed.
Important Terms:-
1. Acute Care:- A level of healthcare that can only be provided in a Hospital.
2. Hospice care:- Any person suffering from terminal illness is eligible for Hospice Care. Hospice is eligible if physician thinks patient will live six months or less.
3. In Patient:- A patient who has stay in Hospital/Health care centre for more than 24hr.
4. Out Patient:- A patient who visit a Hospital/Health care clinic and return after getting the treatment before 24hr.
5. New Patient:- A patient who has never visited a Hospital/Health care clinic for the past 3 years.
6. Established Patient:- A patient who visited a Hospital/Health care centre in the last 3 year.
7. DME:- Durable Medical Equipment are that equipment which can be Re-use again & againExample - Beds, Oxygen cylinder, Wheelchair & canes.
Provider’s Credentialing: -
1. TIN#:- Tax Identification Number – a provider’s federal tax id#. It’s 9 digits through which provider can be identified in the insurance company.
2. PIN#:- Provider Identification Number - It’s number with variable character which is given by insurance company to their network provider. This is 2 types (A) Individual pin# (B) Group pin# - For a facility or group doc.
3. U PIN: - Unique Physician Identification Number - This is 5-digit number preceding with alpha prefix. Used for referring provider (PCP). In case of referral and for radiological services UPIN is must.
4. License Number: - This is a 6-digit number given to every provider to run their practice. This is also must to get the claim paid.
5. W9 Form:- It’s a form send to insurance company to get participating with the insurance company. W9 form includes provider Name, Address, Tin#, SSN & NPI.
Modifiers:-
59 - Distinct Procedural Services - Service is separate from other on same day. Example - January,1,2012 X-ray of palm 76770 January,1,2012 X-ray of finger 76770-59
50 - Bilateral Procedure - Service performed at same operative session. Example - January,1,2012 Operation of right Eye 70553 January,1,2012 Operation of left Eye 70553-50
51 - Multiple Procedures (other than E/M) – More than one procedure performed at same operative session. Example - January,1,2012 Operation of Stomach 91105 January,1,2012 Operation of Appendix 91105-51
21 - This modifier can only be submitted with E&M procedures. Example - When doctor spend some extra time with patient than we must add modifier 21.
25 - Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Example - Same Doc, Same Patient, Same Physician but Different service – X-ray, MRI for same patient.
76 - Repeat procedure by same physician. Example - If provider done X-ray 2 time of same date of service.
77 - Repeat Procedure done by two different physicians
24 - Post operative period. Example – After operation if patient suffer any other problem like – Swelling & Pain.
LT - Left side of orogen.
RT - Right side of orogen.
26 - This modifier is used the professionals Procedure services. Example – Patient gather the any services outside. then facility not available in hospitals.
Place of service codes :-
21 - In patient 22 - Out patient 11 - Office visit 12 - Home visit 23 - Emergency
Important detail:-
SSN - 9 Digit numerical number CPT - 5 Digit code NPI - 10 Digit TIN - 9 Digit U PIN - 5 Digit License no. - 6 Digit ICD - Minimum 3 & max 5 numeric or alphanumeric CPT - 5 Digit numeric or alpha numeric Medicare ID - SSN+1Alpha Modifiers - 2 Digit alphanumeric code Medicaid ID - 2 Prefix 5-digit 1 suffix BCBS ID - 3 Prefix 8 digit Aetna ID - 1 Prefix always "W" and 9 digits
Abbreviations:
SSN - Social Security Number HIPAA - Health Insurance Portability and Accountability Act PHI - Protected Health Information HICN (MCR) - Health Insurance Claim Number NPI - National Provider Identifier (10 digits) TIN - Tax Identification Number (9 digits) PIN - Provider Identification Number U PIN - Unique Provider Identification Number ABN - Advance Beneficiary Notice (Signed By Patient) PCP - Primary Care Physician AOB - Assignment Of Benefits ICD - International Classification if Diseases CPT - Current Procedure Terminology (5 digit) HCPCS - Healthcare Common Procedure Coding System E&M - Evaluation and Management CT - Computerized Tomography MRI - Magnetic Resonance Imagine POS - Place of Service/Point of Service CMS - Center for Medicare and Medicaid Services HCFA-1500 - Health Care Financing Administration EOB - Explanation of Benefits UT - Utilization Threshold BCBS - Blue Cross Blue Shield WC - Workers Compensation NF - No – Fault PIP - Personal Injury Protection COB - Co-ordination of Benefits HMO - Health Maintenance Organization PPO - Preferred Provider Organization POS - Point of Service EPO - Exclusive Provider Organization
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