Health Plans - healing Billing Terms and healing Coding Terminology
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Health Plans! Again, for I know. Ready to share new things that are useful. You and your friends.Those in healing billing and coding careers have a terminology of unique terms and abbreviations. Below are some of the more frequently used healing Billing terms and acronyms. Also included is some healing coding terminology.
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We had a good read. For the benefit of yourself. Be sure to read to the end. I want you to get good knowledge from Health Plans.Aging - Refers to the unpaid guarnatee claims or inpatient balances that are due past 30 days. Most healing billing software's have the potential to originate a detach record for guarnatee aging and inpatient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.
Appeal - When an guarnatee plan does not pay for treatment, an appeal (either by the provider or patient) is the process of formally objecting this judgment. The insurer may need added documentation.
Applied to Deductible - Typically seen on the inpatient statement. This is the amount of the charges, carefully by the patients guarnatee plan, the inpatient owes the provider. Many plans have a maximum each year deductible that once met is then covered by the guarnatee provider.
Assignment of Benefits - guarnatee payments that are paid to the physician or hospital for a patients treatment.
Beneficiary - someone or persons covered by the health guarnatee plan.
Clearinghouse - This is a aid that transmits claims to guarnatee carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be beyond doubt corrected. Clearinghouses electronically send claim data that is compliant with the precise Hippa standards (this is one of the healing billing terms we see a lot more of lately).
Cms - Centers for Medicaid and Medicare Services. Federal group which administers Medicare, Medicaid, Hippa, and other health programs. Once known as the Hcfa (Health Care Financing Administration). You'll consideration that Cms it the source of a lot of healing billing terms.
Cms 1500 - healing claim form established by Cms to submit paper claims to Medicare and Medicaid. Most commercial guarnatee carriers also need paper claims be submitted on Cms-1500's. The form is grand by it's red ink.
Coding -Medical Billing Coding involves taking the doctors notes from a inpatient visit and translating them into the allowable Icd-9 code for determination and Cpt codes for treatment.
Co-Insurance - division or amount defined in the guarnatee plan for which the inpatient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the guarnatee carrier pays 80% and the inpatient pays 20%.
Co-Pay - amount paid by inpatient at each visit as defined by the insured plan.
Cpt Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a course performed by the physician. The Cpt has a corresponding Icd-9 determination code. Established by the American healing Association. This is one of the healing billing terms we use a lot.
Date of aid (Dos) - Date that health care services were provided.
Day Sheet - summary of daily inpatient treatments, charges, and payments received.
Deductible - amount inpatient must pay before guarnatee coverage begins. For example, a inpatient could have a 00 deductible per year before their health guarnatee will begin paying. This could take several doctor's visits or prescriptions to reach the deductible.
Demographics - corporeal characteristics of a inpatient such as age, sex, address, etc. Primary for filing a claim.
Dme - Durable healing tool - healing supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
Dob - Abbreviation for Date of Birth
Dx - Abbreviation for determination code (Icd-9-Cm).
Electronic Claim - Claim data is sent electronically from the billing software to the clearinghouse or directly to the guarnatee carrier. The claim file must be in a proper electronic format as defined by the receiver.
E/M - evaluation and administration section of the Cpt codes. These are the Cpt codes 99201 thru 99499 most used by physicians to way (or evaluate) a patients rehabilitation needs.
Emr - Electronic healing Records. healing records in digital format of a patients hospital or provider treatment.
Eob - Explanation of Benefits. One of the healing billing terms for the statement that comes with the guarnatee enterprise payment to the provider explaining payment details, covered charges, write offs, and inpatient responsibilities and deductibles.
Era - Electronic Remittance Advice. This is an electronic version of an guarnatee Eob that provides details of guarnatee claim payments. These are formatted in agreeing to the Hipaa X12N 835 standard.
Fee program - Cost linked with each rehabilitation Cpt healing billing codes.
Fraud - When a provider receives payment or a inpatient obtains services by deliberate, dishonest, or misleading means.
Guarantor - A responsible party and/or insured party who is not a patient.
Hcpcs - health Care Financing administration base course Coding System. (pronounced "hick-picks"). This is a three level ideas of codes. Cpt is Level I. A standardized healing coding ideas used to report definite items or services provided when delivering health services. May also be referred to as a course code in the healing billing glossary.
The three Hcpcs levels are:
Level I - American healing Associations Current Procedural Terminology (Cpt) codes.
Level Ii - The alphanumeric codes which consist of mostly non-physician items or services such as healing supplies, ambulatory services, prosthesis, etc. These are items and services not covered by Cpt (Level I) procedures.
Level Iii - Local codes used by state Medicaid organizations, Medicare contractors, and hidden insurers for definite areas or programs.
Hipaa - health guarnatee Portability and accountability Act. several federal regulations intended to enhance the efficiency and effectiveness of health care. Hipaa has introduced a lot of new healing billing terms into our vocabulary lately.
Hmo - health Maintenance Organization. A type of health care plan that places restrictions on treatments.
Icd-9 Code - Also know as Icd-9-Cm. International Classification of Diseases classification ideas used to assign codes to inpatient diagnosis. This is a 3 to 5 digit number.
Icd 10 Code - 10th revising of the International Classification of Diseases. Uses 3 to 7 digit. Includes added digits to allow more ready codes. The U.S. group of health and Human Services has set an implementation deadline of October, 2013 for Icd-10.
Inpatient - Hospital stay longer than one day (24 hours).
Maximum Out of Pocket - The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the guarnatee typically then pays 100% of eligible expenses.
Medical Assistant - Performs administrative and clinical duties to sustain a health care provider such as a physician, physicians assistant, nurse, or nurse practitioner.
Medical Coder - Analyzes inpatient charts and assigns the precise Icd-9 determination codes (soon to be Icd-10) and corresponding Cpt rehabilitation codes and any linked Cpt modifiers.
Medical Billing expert - The someone who processes guarnatee claims and inpatient payments of services performed by a physician or other health care provider and vital to the financial doing of a practice. Makes sure healing billing codes and guarnatee data are entered correctly and submitted to guarnatee payer. Enters guarnatee payment data and processes inpatient statements and payments.
Medical Necessity - healing aid or course performed for rehabilitation of an illness or injury not carefully investigational, cosmetic, or experimental.
Medical Transcription - The conversion of voice recorded or hand written healing data dictated by health care professionals (such as physicians) into text format records. These records can be whether electronic or paper.
Medicare - guarnatee provided by federal government for habitancy over 65 or habitancy under 65 with obvious restrictions. Medicare has 2 parts; Medicare Part A for hospital coverage and Part B for doctors office or inpatient care.
Medicare Donut Hole - The gap or difference between the first limits of guarnatee and the catastrophic Medicare Part D coverage limits for prescription drugs.
Medicaid - guarnatee coverage for low earnings patients. Funded by Federal and state government and administered by states.
Modifier - Modifier to a Cpt rehabilitation code that furnish added data to guarnatee payers for procedures or services that have been altered or "modified" in some way. Modifiers are leading to illustrate added procedures and derive reimbursement for them.
Network provider - health care provider who is contracted with an guarnatee provider to furnish care at a negotiated cost.
Npi amount - National provider Identifier. A unique 10 digit identification amount required by Hipaa and assigned through the National Plan and provider Enumeration ideas (Nppes).
Out-of Network (or Non-Participating) - A provider that does not have a contract with the guarnatee carrier. Patients normally responsible for a greater part of the charges or may have to pay all the charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum amount the inpatient is responsible to pay under their insurance. Charges above this limit are the guarnatee associates obligation. These Out-of-pocket maximums can apply to all coverage or to a definite benefit kind such as prescriptions.
Outpatient - Typically rehabilitation in a physicians office, clinic, or day surgical operation facility chronic less than one day.
Patient accountability - The amount a inpatient is responsible for paying that is not covered by the guarnatee plan.
Pcp - primary Care physician - normally the physician who provides first care and coordinates added care if necessary.
Ppo - preferred provider Organization. guarnatee plan that allows the inpatient to elect a physician or hospital within the network. Similar to an Hmo.
Practice administration Software - software used for the daily operations of a providers office. Typically includes appointment scheduling and billing functions.
Preauthorization - Requirement of guarnatee plan for primary care physician to forewarn the inpatient guarnatee carrier of obvious healing procedures (such as inpatient surgery) for those procedures to be carefully a covered expense.
Premium - The amount the insured or their owner pays (usually monthly) to the health guarnatee enterprise for coverage.
Provider - physician or healing care facility (hospital) that provides health care services.
Referral - When a provider (typically the primary Care Physician) refers a inpatient to another provider (usually a specialist).
Self Pay - payment made at the time of aid by the patient.
Secondary guarnatee Claim - guarnatee claim for coverage paid after primary guarnatee makes payment. Typically intended to cover gaps in guarnatee coverage.
Sof - Signature on File.
Superbill - One of the healing billing terms for the form the provider uses to document the rehabilitation and determination for a inpatient visit. Typically includes several ordinarily used Icd-9 determination and Cpt procedural codes. One of the most frequently used healing billing terms.
Supplemental guarnatee - added guarnatee course that covers claims fro deductibles and coinsurance. frequently used to cover these expenses not covered by Medicare.
Taxonomy Code - Code for the provider specialty sometimes required to process a claim.
Tertiary guarnatee - guarnatee paid in addition to primary and secondary insurance. Tertiary guarnatee covers costs the primary and secondary guarnatee may not cover.
Tin - Tax Identification Number. Also known as owner Identification amount (Ein).
Tos - Type of Service. record of the kind of aid performed.
Ub04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to Cms 1500. Replaces the Ub92 form.
Unbundling - Submitting more than one Cpt rehabilitation code when only one is appropriate.
Upin - Unique physician Identification Number. 6 digit physician identification amount created by Cms. Discontinued in 2007 and replaced by Npi number.
Write-off (W/O) - The difference between what the provider charges for a course or rehabilitation and what the guarnatee plan allows. The inpatient is not responsible for the write off amount. May also be referred to as "not covered" in some glossary of billing terms.
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