US Medical Billing Cycle

MEDICAL BILLING CYCLE

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CO

OK

TXLA

FL

MN

IA

IL

ME

AZNM

KS

WI

OH

MINY

VT

IN

MO

AR

KY

TN

NH

PARI

MS

AL

SC

NC

GA

VAWV

MA

CT

NJ

DE

MD

AK

HI

Omega Proprietary & Confidential

Once again, because I know how confused we all get..:) Colorado is MOUNTAIN TIME. So that means 9:30pm for me here in Eastern Time. I promise you all, by the end of tour, you'll know your time zones. We Can Do It!! <3


List of States in US

State Capitals of the United States

State Abr. Capital Notes

Alabama AL Montgomery Birmingham is the state's largest city.

Alaska AK Juneau Juneau is the largest capital by land area. Anchorage is the state's largest city.

Arizona AZ Phoenix Phoenix is the most populous U.S. state capital.

Arkansas AR Little Rock

California CA SacramentoThe Supreme Court of California is headquartered in San Francisco. Los Angeles is the state's largest city.

Colorado CO Denver

Connecticut CT Hartford Bridgeport is the state's largest city, but Greater Hartford is the largest metro area.




Delaware DE Dover Longest-serving capital in terms of statehood. Wilmington is the state's largest city.

Florida FL Tallahassee Jacksonville is the largest city, and Miami has the largest metro area.

Georgia GA Atlanta

Hawaii HI Honolulu

Idaho ID Boise

Illinois IL Springfield Chicago is the state's largest city.

Indiana IN IndianapolisIn addition to being the second-largest state capital, Indianapolis is also the second largest city in the Midwest.

Iowa IA Des Moines




Kansas KS Topeka Wichita is the state's largest city.

Kentucky KY Frankfort Louisville is the state's largest city. Frankfort ranks as the twelfth most populous city in the state.

Louisiana LA Baton Rouge New Orleans is the state's largest city and home to the Louisiana Supreme Court.

Maine ME AugustaAugusta was officially made the capital 1827, but the legislature did not sit there until 1832. Portland is the state's largest city.

Maryland MD Annapolis

Annapolis is the third-longest serving capital in the United States after Santa Fe and Boston. Its capitol building is the oldest still in use. It is also the smallest capital by land area. Baltimore is the state's largest city.


State Capitals of the United StatesState Abr. Capital Notes

Massachusetts MA Boston

Boston is the longest continuously serving capital in the United States. The Boston-Worcester-Manchester Combined Statistical Area encompasses the state capitals of Massachusetts, New Hampshire, and Rhode Island.

Michigan MI Lansing

Lansing is the only state capital that is not also the county seat of the county in which it is situated. Detroit is the state's largest city.

Minnesota MN Saint PaulMinneapolis is the state's largest city; it and Saint Paul form the core of the state's largest metropolitan area.

Mississippi MS Jackson

Missouri MO Jefferson CityKansas City is the state's largest city, and Greater St. Louis is the state's largest metropolitan area.

Montana MT Helena Billings is the state's largest city.




Nebraska NE Lincoln Omaha is the state's largest city.

Nevada NV Carson City Las Vegas is the state's largest city.

New Hampshire NH Concord Manchester is the state's largest city.

New Jersey NJ Trenton Newark is the state's largest city.

New Mexico NM Santa Fe

Santa Fe is the longest serving capital in the United States. El Paso del Norte served as the capital of the Santa Fe de Nuevo México colony-in-exile during the Pueblo Revolt of 1680–1692. Santa Fe has the highest elevation of any state capital. Albuquerque is the state's largest city.

New York NY Albany New York City is the state's largest city.

North Carolina NC Raleigh Charlotte is the state's largest city.

North Dakota ND Bismarck Fargo is the state's largest city.




Ohio OH Columbus

Columbus is Ohio's largest city, and the fourth-largest state capital, but the Cincinnati and Cleveland metropolitan areas are both larger.

Oklahoma OK Oklahoma CityOklahoma City is the shortest serving current state capital in the United States.

Oregon OR Salem Portland is the state's largest city.

Pennsylvania PA Harrisburg Philadelphia is the state's largest city.

Rhode Island RI Providence

Providence also served as the capital 1636–1686 and 1689–1776. It was one of five co-capitals 1776–1853, and one of two co-capitals 1853–1900.

South Carolina SC Columbia

South Dakota SD Pierre Sioux Falls is the state's largest city.

Tennessee TN Nashville Memphis is the state's largest city, and Nashville is the largest metro area.

Texas TX Austin

Houston is the state's largest city and the previous capital, and Dallas–Fort Worth is the largest metro area. It is the largest state capital that is not also the state's largest city.




Utah UT Salt Lake City

Vermont VT MontpelierMontpelier is the least populous U.S. state capital. Burlington is the state's largest city.

Virginia VA RichmondVirginia Beach is the state's largest city, and Northern Virginia is the state's largest metro area.

Washington WA Olympia Seattle is the state's largest city.

West Virginia WV Charleston

Wisconsin WI Madison Milwaukee is the state's largest city.

Wyoming WY Cheyenne


English Phonetic Spelling


Word AbbreviationAir Force Base AFBApartment AptAvenue AveBasement BsmtBoulevard BlvdBuilding BldgBypass BypCenter CtrCircle CirCourt CtCrescent CresCrossing XingDepartment DeptDrive DrEast EExpressway ExpyExtension ExtFloor FlFort FtFreeway FwyHeights HtsHighway HwyHospital Hosp

Institute InstInternational IntlJunction JctLake LkLakes LksLane LnMeeting Mtg

Word Abbreviation

Postal Abbreviations


Word Abbreviation

Memorial Mem

Mount Mt

Mountain Mtn

National Nat

Naval Air Station NAS

North N

Northeast NE

Northwest NW

Parkway Pky

Place Pl

Point Pt

River Riv

Road Rd

Room Rm

Rural Route RR

Word Abbreviation

Saint St

South S

Southeast SE

Southwest SW

Square Sq

Station Sta

Street St

Suite Ste

Terminal Term

Terrace Ter

Trail Trl

Trailer Trlr

Turnpike Tpk

University Univ

West W

Postal Abbreviations


Medical Billing is:

•Obtaining insurance information.

•Verifying insurance coverage.

•Making patient appointments.

•Gathering medical information.

•Maintaining the privacy of that information.

•Transferring Diagnostic and Treatment information into highly-specialized codes.

Billing Cycle - http://www.sweans.com/medical_billing_process_flow_chart.html


This may be handled either directly by the doctor or by his staff or by a third party professional medical billing company if it is for a bigger clinic or hospital. Medical billing is a specialized profession today and billing could be a team work process that can involve the following people.

Office manager Nurse Receptionist Medical assistant Insurance clerk Medical coders

Details Needed For Medical Billing

The medical claim process begins with proper identification and medical coding as all medical procedures and diagnoses have been assigned with codes. The Current Procedural Terminology (CPT) was developed in the year 1966 by (AMA) American Medical Association and it lists medical procedures and corresponding codes. Each medical procedure has a unique code that is listed in a CPT manual. What are the types of details that are required during the medical billing process? They include,


1. Name, address, telephone number, and ID number of provider 2. Name of insurance company / group 3. ID number of insurance holder 4. Patient's name, date of birth/address/phone no 5. Insured person's name, date of birth/address/phone 6. Relationship between patient and insured person 7. Details of provider name, address, telephone number, and ID number 8. Details of other health insurances 9. Patient's medical history /condition 10.Details whether the medical condition is related to accident etc

A document called the explanation of benefits (EOB) often may accompany the payment that is received from the insurance or managed care company. This document describes all the details of services covered and not covered. It also mentions all the bills that have been sent to the service provider and the patient. One can also know if the patient has missed out on his annual payments/deductibles to the insurance company making him ineligible for total claim.

Details Needed For Medical Billing……




• Transferring insurance information, patient information and coded diagnosis and treatment information to a standard billing form or format.

• Following up with insurers for tracking of payments.

• Posting credits of payments made by insurance and patients.

Medical Billing is:


Subjects Covered

• Medical Information and the Law. Confidentiality, HIPAA, Malpractice, Fraud and Abuse.

• The medical claim cycle – appointment to payment audit.

• Insurance Terminology, Insurance Plans.

• Medical and Financial Documentation: the Chart Notes, the Superbill and the Ledger.


• Coding of Diagnostic information (ICD-9-CM coding).• Coding of Treatment Procedures

and Supplies (CPT and HCPCS coding).• Completion of the CMS-1500 claim

form data elements.

Subjects Covered


• Private Insurance Plans.• Government Health Plans

(Medicare, Medi-Cal, Tricare, ChampVA)• Funding structures: Fee-for-

service versus Capitation.• Provider contracts.• Reading the Insurance Explanation

of Benefits.

Subjects Covered


• Write-off/adjustment amounts and balance billing.• Coordination of Benefits

between multiple insurances.• Patient Advocacy.• Collections.• Job Search strategies.

Subjects Covered


Billing Cycle


Suffice to understand that no one gets treatment unless an appointment is created. Even if someone is carried into a medical facility...it's still considered an appointment. And believe it or not, a lot of marketing work goes into increasing the number of appointments by bigger group practices and other medical facilities. If no one knows that a certain doctor even exists, well the number of appoints are going to be pretty low or none.

Patient Appointment:

Usually, the best time to collect the needed information like the patient demographics and insurance information is at the time the appoint is being setup. In most cases, it's done over the phone. That shouldn't be problem because all that the doctor's office would need is the basic patient info and basic carrier info. Once in a while the doctors receptionist might hear of an unknown carrier. It's best to get the carriers address and phone from the back of the card in cases like these.

Demographic & Coverage Entry:


03 - Eligibility Check:The reason it's so important is because the doctors office can be given fictitious or outdated info and the provider wouldn't even know until it's too late (weeks or months down the road). One of our clients confirmed eligibility over the phone. So here was a quick equation for us make a decision...the provider attended just 10 patients a day.

10ptEach patients eligibility took only 5 minutes to be confirmed over the phone.10pt x 5min. = 50min/dayThe facility treated patients only 5 days a week. Which is an average of 22 days a month.50min x 22days = 1,100min. were spent on eligibility check a month. Or about 18hrs


04 - Service Rendered:

This is when the patient is rendered medical service by the provider. This step in the cycle is the basis all the other things are done. This makes the patients feel better and treats them for their illnesses.

05 - Billing Work Sent:

All information including: Patient Demographics, Carrier Details, Eligibility, and Service Information is passed up to the biller who at times determines the best coding to be used for service as well as diagnosis to bill to the carrier. If no insurance carrier is involved, the bill is sent to the patient.06 - Payment Followup:

Now, sending the billing work to the carrier isn't always enough. Sometimes the billing people have ring telephones and knock the metaphoric doors. Sometimes, we have to remind the carrier about the bills and sometimes we have to find out why or how a payment wasn't made or has been delayed. Let me assure you, that this step is "CRITICAL" to any medical billing practice. Poor followup or no followup means a financial toll on the provider. Plain & Simple!


07 - Payment Entry:

Then the day comes when the long awaited payments come in. But now what? First, they are too strangely put together on the paper. And second, there are multiple payments on the same check. But a billing person knows exactly how to enter the payments the way that it should be entered. Remember, the billing person is first part of bookkeeping and accounting staff and then a medical administrator.

At times you'll come across patients with multiple insurance carrier. If that happens, then the steps 5, 6, & 7 are repeated until the balance is zeroed out. We hope you have finally understand the cycle. It's pretty straight forward if you deal with it day in and day out.


Insurance VerificationInsurance eligibility verification is the foundation of the medical insurance billing cycle and it has the power to decide the fate of a claim. At times we don’t give adequate significance to doing insurance eligibility verification. We have an impression that certain claims don’t require insurance eligibility verification and we fail to foresee the consequences that we would have to face by not doing the verification. When it comes to business, big or small, a loss is a loss. The loss is to be borne by physicians or patients. Even the medical billing companies are at loss if there are delays and denials. To avoid this unpleasant situation, we need to adhere to a better and streamlined process flow which will be initiated by doing insurance eligibility verification irrespective of whether it is an ordinary health plan, PIP or workmen compLet's discuss about the major issues arising out of non verification

of insurance which would lead to denials if not handled appropriately.1) Verifying the effective date is essential to avoid denials due to expiry of insurance coverage2) In certain cases, patient’s primary insurance gets expired and he/she uses the secondary insurance that doesn’t cover the ailment in which case the claim will be denied.


Insurance Verification.....

3) Patient would not have paid the premium and his/her insurance coverage would have expired. It is important for the physician to know this earlier in order to make out payment details from the patient.

4) To find the primary insurance carrier of a patient, it is essential to do insurance eligibility verification.

5) In case the patient is covered under multiple health plans, insurance eligibility verification is essential to avoid wrong billing for a different health plan.6) At times patient would have changed his/her health plan but would have not informed about the change to the provider. Many complications might arise due to this and it is advisable to do insurance eligibility verification.7) Certain insurance carriers accept the claim only if it is submitted in the name of a physician who is qualified for that service.

8) At times, when there is a mismatch in the information regarding the primary care physician, claims would be denied. Certain carriers are strict about this and it is essential to do insurance eligibility verification.


Insurance Verification.....9) The possibilities of claim denial are more when the provider is not in par with the insurance company.

10) Deductibles, co-pays: It is inevitable to check if there are deductibles and co-pay for the patient in order to avoid any confusions with the payment

11) Diseases occurring due to pre-existing conditions like diabetic retinopathy and diabetic kidney disease are not covered by some insurance carriers

12) For certain services pre-authorization is essential from the insurance carriers and if not the claims would be denied

13) Insurance carriers set up visit limits to the insured and incase if the visit limit of the patient has exceeded, then it will not be covered under insurance plan.

14) Some lab services are not covered under certain health plans and the claims are likely to get denied if the lab tests are not done in a preferred lab. Physicians should know this in advance so that he/she can discuss this with patients and decide accordingly.15) Certain insurance carriers don’t provide insurance coverage for routine checkups and it is necessary for the physician to know this in advance

16) At times the health plan possessed by a patient might not provide coverage for certain diseases and the claim would be denied. To avoid such denials, insurance eligibility verification is essential.


17) In case of workmen compensation, it is necessary to do insurance eligibility verification in order to know who the adjustor is.

18) In workmen compensation, knowing the compensable body part is essential in order to avoid uncertainty with the insurance coverage.

By doing effective insurance eligibility verification, healthcare organizations can avoid losses, delays and reworks. Insurance eligibility verification also saves valuable time by avoiding the unnecessary billing process for a claim which is sure to get denied due to issues with the insurance coverage.

Insurance Verification.....


Glossary of Billing Terms -A-Account - Charges for a medical visit Account Number - A number assigned to each patient’s episode of service that is used to identify the account and all charges and account activityAdjustment - The portion of a medical bill for which a doctor or hospital has agreed not to charge Admission Date (Admit Date) - Date patient admitted for treatment Admission Hour - Hour when admitted for inpatient or outpatient care Admitting Diagnosis - Words that a doctor uses to describe a medical condition Advance Beneficiary Notice (ABN) - A notice the hospital or doctor gives before treating a Medicare patient, telling them that Medicare will not pay for some treatment or services. The notice is given so that Medicare patients are aware of non-covered treatment or services, and may decide before treatment is provided whether to proceed with the treatment and how to pay for itAdvance Directive (Healthcare) - Written prior to treatment, a healthcare advance directive is a document that says how a patient would like medical decisions to be made if the patient loses the ability to make decisions. A healthcare advance directive may include a living will and a durable power of attorney for health care Amount Charged - The amount a doctor or hospital bills a patient Amount Not Covered - What an insurance company does not pay. It includes deductibles, co-insurances and charges for non-covered services. Amount Paid - The dollar amount a patient pays for a doctor or hospital visit


Glossary of Billing Terms ………Amount Payable by Plan - How much an insurer pays for patient treatment, minus any deductibles, coinsurance or charges for non-covered services Anesthesia - Drugs given to a patient during surgery to eliminate or reduce pain resulting from the surgical procedure Appeal - The process by which a patient, doctor, or hospital can disagree with the health plan's decision to not pay for care Applied to Deductible - Portion of a patient's bill, as defined by an insurance company, that he or she owes a doctor or hospital Attending Physician Name - The doctor who certifies that a patient needs treatment and is responsible for the patient's care Assignment - An agreement a patient signs that allows an insurance company to pay a doctor or hospital Assignment of Benefits (AOB) - When insurance payments are sent directly to a doctor or hospital Authorization Number - A number stating that a patient's treatment has been approved by his or her insurance plan. Also called a certification number or prior-authorization number

Black Lung Program - A federal workers compensation plan, administered by the U. S. Department of Labor, that provides coverage to employees not covered or inadequately covered under state workers compensation programs. All Medicare services for patients with diagnoses related to black lung are billed to the Department of Labor for reimbursement.


Glossary of Billing Terms ………-B-Balance Bill - How much doctors and hospitals charge a patient after the patient's health plan, insurance company or Medicare has paid its approved amount Beneficiary - The person who is entitled to receive Medicare benefits and who maintains a health insurance claim numberBeneficiary Eligibility Verification - A way for doctors and hospitals to get information about whether a patient has insurance coverage Beneficiary Liability - A statement that a patient is responsible for some treatments or charges Benefit - The amount an insurance company pays for medical services Bill/Invoice/Statement - Printed summary of a medical bill-C-

Claim - A medical bill that is sent to an insurance company for processing Claim Number - A number given to a medical service Coinsurance - The cost-sharing part of a bill that a patient has to pay Co-pay - Agreed amount of the charges for medical services that patients or guarantors must pay Consent (for treatment) - An agreement signed by a patient giving permission to receive medical services or treatment from doctors or hospitals Contractual Adjustment - 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 Coordination of Benefits (COB) - A way to decide which insurance company is responsible for payment if a patient has more than one insurance plan Co-payment - A cost-sharing part of a bill that is a patient's responsibility to pay, also known as co-pay Covered Benefit - A health service or item that is included in a health plan, and that is paid for either partially or fully Covered Days - Days that an insurance company pays for in full or in part


Glossary of Billing Terms ………-D-

Deductible - How much cost-sharing a patient must pay for medical services, often before the insurance company starts to pay Discharge Hour - Time of day when a patient was discharged

-E-

Enrollee - A person who is covered by health insurance Explanation of Benefits (EOB/EOMB) - The notice received by a patient from an insurance company after receiving medical services from a doctor or hospital. It details what was billed, the payment amount approved by insurance, the amount paid, and the amount to pay

-F-Financial Assistance - Assistance for patients who have financial hardship and difficulty paying their medical bill

-G-

Guarantor - The person responsible for paying the patient's bill. Typically, the guarantor is the patient's parent or guardian-H-

Healthcare Provider - Someone who provides medical services, such as doctors, hospitals or laboratories. This term should not be confused with insurance companies, that provide insurance HIPAA - Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of patient health information Home Health Agency - An agency that treats patients in their homes


Glossary of Billing Terms ………-I-

Insured Group Name - Name of the group or insurance plan that insures an individual, usually an employer Insured Group Number - A number that an insurance company uses to identify the group under which a patient is insured Insured's Name (Beneficiary) - The name of the insured person

-N-

Non-Covered Charges - Charges for medical services denied or excluded by an insurance company. A patient may be billed for these charges Non-Participating Provider - A doctor, hospital or other healthcare provider who is not part of an insurance plan's doctor or hospital network

-O-

Out-Of-Pocket Costs - Costs a patient is responsible for because their insurance does not cover them-P-

Paid To Provider - Amount the insurance company pays a medical provider directly Paid To You - Amount the insurance company pays the patient or guarantor Participating Provider - A doctor or hospital that agrees to accept an insurance payment for covered services as payment in full, minus the patient's deductibles, co-pays and coinsurance amounts Patient Amount Due - The amount charged by a doctor or hospital for which the patient is responsible Pre-Existing Condition - A health condition or medical problem that a patient already has before receiving insurance. Some health insurers may not pay for pre-existing health conditions Pre-payments - Money a patient pays before getting medical care; also referred to as pre-admission deposits


Glossary of Billing Terms ………-R-

Release of Information - A signed statement from a patient or guarantor that allows doctors and hospitals to release medical information

-S-

Secondary Insurance - Extra insurance that may pay some charges not paid by a patient's primary insurance company. Whether payment is made depends on insurance benefits, insurance coverage and benefit coordination

-T-

Total Charges - Total cost of medical services

-U-

U4 - A form used by hospitals to file insurance claims for medical services


Glossary of Billing Terms ………Capitation: A method of reimbursement where medical services are provided by a health plan for a fixed monthly fee.

CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) : A program that covers the health benefits for families of all uniformed services employees.

CHAMPVA (Civilian Health and Medical Program of the Veteran’s Administration): A program similar to CHAMPUS under which the insured must be a disabled veteran’s spouse or dependant or a survivor of those who died of service-related causes.

Clean Claim: For Medicare purposes, a claim that the fiscal intermediary (FI) does not need to investigate outside of the FI’s operation on a prepayment basis; a claim for which the intermediary receives, within seven days of a query, a definitive response that provides all the eligibility data necessary to process it; a claim that passes all electronic edits, a claim that is investigated on a post-payment basis, or a claim that is subject to medical review but is submitted with complete information attached or is forwarded simultaneously according to electronic media claims instructions.

Clinic: An outpatient facility that provides scheduled diagnostic, curative, rehabilitative and/or educational services for ambulatory patients.

Co-insurance: The portion or percentage of the Medicare-approved amount that a beneficiary is responsible for paying.

Contractual Allowance: The difference between the health care facility’s published rates and the cost deemed allowable by the third-party payor.


Employer Group Health Plan: Any health plan that is contributed to be an employer of 20 or more employees and that provides for medical care directly or through other methods.

Explanation of Medicare Benefits (EOMB): A statement issued by Medicare to the beneficiary to explain how Medicare processed, paid or rejected a submitted claim. The statement also indicates any deductibles or co-insurance amounts that have been applied.

Group Health Plan: A plan that provides health care, either directly or indirectly, through insurance and is contributed to or sponsored by an employer.

HCFA 1500: The claim form required by Medicare and some other payors for billing physician services.

HCPCS (HCFA Common Procedure Coding System): Level 1 is a numeric coding system used by hospital outpatient departments and ASC’s to code ambulatory, lab, radiology, and other diagnostic services for Medicare billing. Level II is a national coding system, developed by HCFA, that contains alphanumeric codes for physician and non-physician services not included in the CPT-4 coding system, such as ambulance services, DME and prosthetic devices.

Health Care Financing Administration: (HCFA) The federal agency primarily responsible for administering the Medicare program and federal participation in the Medicaid program.

Health Maintenance Organization (HMO): A managed care plan that offers a menu of Healthcare services to its members by its preferred providers; usually, members prepay for the services to be received through monthly premiums.

Glossary of Billing Terms ………


Home Health Agency: A public or private agency that specializes in giving skilled nursing services and other therapeutic services, such as physical therapy, in the home.

ICD9-CM: (International Classification of Diseases, Ninth Revision, Clinical Modification) A statistical coding system used to report, compile and compare health care data, using numeric and alphanumeric codes, in order to assist in the evaluation, planning, delivery, reimbursement and quantifying of medical care.Independent Practice Association (IPA): An HMO contracting directly with physicians who practice in their own private offices and are reimbursed on a fee-for-service basis.

Medicaid: A health insurance program jointly funded by the federal government and the states to provide medical care to people who are unable to pay their own medical expenses.

Medicare Secondary Payor (MSP): Specified circumstance when beneficiaries are covered by other third-party payors and Medicare is the secondary payor. MSP prohibits Medicare payment for items or services if payment has been made or can reasonably be expected to by made by another payor.No-Fault Insurance: Insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy or operation of an automobile, regardless of who may have been responsible for causing the accident.

Non-patient Services: Services that are not rendered to a patient seen at the hospital. This typically refers to laboratory tests performed on samples sent to the hospital laboratory from an outside source for processing.

Out-of-Pocket Limits: The maximum amount of health care charges for which a patient may be responsible within a specified time frame, e.g., $500 per calendar year.

Glossary of Billing Terms ………


Independent Practice Association (IPA): An HMO contracting directly with physicians who practice in their own private offices and are reimbursed on a fee-for-service basis.

Medicaid: A health insurance program jointly funded by the federal government and the states to provide medical care to people who are unable to pay their own medical expenses.

Medicare Secondary Payor (MSP): Specified circumstance when beneficiaries are covered by other third-party payors and Medicare is the secondary payor. MSP prohibits Medicare payment for items or services if payment has been made or can reasonably be expected to by made by another payor.

No-Fault Insurance: Insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy or operation of an automobile, regardless of who may have been responsible for causing the accident.Non-patient Services: Services that are not rendered to a patient seen at the hospital. This typically refers to laboratory tests performed on samples sent to the hospital laboratory from an outside source for processing.

Out-of-Pocket Limits: The maximum amount of health care charges for which a patient may be responsible within a specified time frame, e.g., $500 per calendar year.


Part A of Medicare: The hospital insurance portion of Medicare. It was established by Section 1811 of Title XVIII of the Social Security Act of 1965, as amended, and covers inpatient hospital care, skilled nursing facility care, some home health agency services, and hospice care.

Part B of Medicare: The supplementary or physician’s insurance portion of Medicare. It was established by Section 1831 of Title XVIII of the Social Security Act of l965, as amended, and covers services of physicians/other suppliers, outpatient care, medical equipment and supplies, and other medical services not covered by Part A.

Participating Physician: A physician who has signed an agreement to accept assignment on all Medicare claims.

Peer Review Organization: An organization that contracts with HCFA to conduct preadmission, pre-procedure and post discharge medical reviews and determine medical necessity, appropriateness and quality of certain inpatient and outpatient surgical procedures for which payment may be made in whole or in part under the Medicare program.

Pre-existing Condition: A symptom that causes a person to seek diagnosis, care or treatment or for which medical advice or treatment was recommended or received by a physician within a certain time period before the effective date of medical insurance coverage. The pre-existing condition waiting period is the time the beneficiary must wait after buying health insurance before coverage begins for a condition that existed before coverage was obtained.


Precertification: The process of obtaining permission from the insurance carrier prior to performing a medical service.

Preferred Provider: A health care provider that has been approved by a health care purchaser (HMO, managed care plan, etc) to offer health care services to its members.

Primary Payor: The insurance company whose coverage of the insured individual takes precedence in the payment of a hospital or medical bill when two or more insurers may be responsible for paying the claim.

Professional Component: The charges associated with a professional service provided to a patient by a hospital-based physician.

Remittance Advice: A statement, voucher or notice that a provider of services receives from Medicare to reflect finalized claims, either paid or denied.

Secondary Payor: The insurer who pays, according to its coverage guidelines, any residual balance remaining after another insurer pays the claim.Skilled Nursing Facility (SNF): A specially qualified facility that has the staff and equipment to provide nursing care or rehabilitation services and other health related services.

Workers Compensation: Payment for health-related services resulting from employment-related illness or injury. Usually self funded by the employer or funded through a third-party administrator.

Working Aged: Employed people aged 65 or over and people aged 65 or over with employed spouses of any age who have group health plan coverage because of their or their spouse’s current employment.



Thank You

Documents

US Medical Billing Cycle