Cash/Payment Posting
Work/ Job Profile: I was posting the payment through EOB, which was received from insurance
company, and I was posting the Auto payment through ERA and end of the day I was preparing the
recon log for the same. Means whatever I posted entire day I need to mention in Recon sheet.
For reconciliation if any batch did not reconcile then I was pulling the system generated report then
after I match one by one payment through EOB, Once I found the difference in any payment then we
post that amount and reconcile the batch.
Reason for leaving EXL: Actually, my process ram down due to covid 19 and management want
to move me in other process, which was not relevant to medical billing, hence I resign and
looking other job.
Sir as you know there was less vacancies’ due to pandemic situation but now, I am getting
opportunity for new companies, Hence I am trying for it.
Target for manual posting: 450
Target for Auto Posting: 750
Software : eCW ( eClinic)
Medical Billing: Medical billing is the process of submitting and following up on the claim to
insurance company in order to receive the payment for service rendered by a healthcare
provider.
US Goverment Insurance Us Commercia Ins./Private
Medicare BCBS Largest Commercial Insurance Company in US
Medicaid Aetna
Tricare Cigna
Champva AARP
Worker compensation ( WC) UHC
No fault insurance
Managed care plan ( HMO, PPO, POS, EPO)
What is RCM (Revenue Cycle Management): :Revenue Cycle Management (RCM) refers to the
process of identifying, collecting and managing the practice's revenue from payers based on the
services provided.
Flow chart of RCM
Patient - Provider - Billing office -MT Team- Medical Coding - Editing - Charge Posting -
Payment (Posting Team)-Denial (AR Team)
Payment posting: payment posting means entering the payment details in to the software.
Charge Posting: In charge posting we have to enter patient diseases treatment of that diseases
on a particular DOS in our software.
We can submit the claim to the insurance company through paper or
electronically.
HCFA-1500/CMS 1500 form: use For physician billing.
UB -04 form: it is use for hospital billing,
What is the difference between the CMS 1500 and UB 04?
The UB-04 (CMS 1450) is a claim form used by hospitals, nursing
facilities, in-patient, and other facility providers. ... On the other hand,
the HCFA-1500 (CMS 1500) is a medical claim form employed by individual
doctors & practices, nurses, and professionals, including therapists,
EOB: Explanation of Benefits): - This is a document that is sent by insurance company to the provider
which contains all the payment or Denial Details. It is use for manual posting.
ERA: Electronic Remittance Advice): It is digital form of the EOB and it is use for auto posting.
COB: Coordination of Benefits): - When a patient is having more than one insurance that is called COB.
and it is decided by patient that which insurance pay as primary and which will pay as secondary.
ABN: Advance Beneficiary Notice): - This is a form which is signed by patient, in this form mentioned
that if Medicare Denied making payment than patient will be responsible for making payment to the
provider.
AOB: Assignment of Benefits): - This is a form which is signed by patient to collect the patient’s
benefits from his/ her insurance company.
Authorization or Pre -authorization : It is a kind of number which is taken by the
provider from insurance company for some expensive services.
Worker Compensation ins. It is government sponsored healthcare program which cover work
related injury, illness or death with regardless like who has fault an employee or college of the
employee or any third person.
Allowed Amount: The fix amount which is set by insurance company for the services performed by the
provider is called allowed amount.
Billed Amount: The amount which is charged by the provider as a compensation for his/her services is
billed amount.
Copay (PR3): It is a small dollar amount which is paid by the patient to provider on every visit. It is a just
like doctor fee.
Co-insurance (PR2): It is specified (%) percentage of allowed amount which patient or secondary Ins. has
to pay to the provider.
Deductible (PR1): It is a fixed amount which is paid by patient to the provider on annual basis only then
after insurance company start giving benefit to the patient. Then he will not get the coverage
Write off Amount: The difference between billed and allowed amount in case of participating provider
is called as write – off amount.
Balance Bill: The difference b/w billed and allowed amount. In case of non-participating provider is
called as balance bill.
For Example:
In case of participating provider Non-Participating Provider
Billed amount- 500
Allowed amount: 300
PR 3: Billed amount- 500
Ins paid - 280 Allowed amount: 300
Write off: Billed - allowed Ins paid - 300
: 500 - 300 = 200 (Write Of Balance Bill: Billed - allowed
amount) : 500 - 300 = 200 (Balance bill)
TFL: Timing Filing Limit): This is a time duration which is given by insurance company in which we
have to submit the claim to the insurance company. This is calculated from date of service.
APPEAL LIMIT: It is the time duration in which, we can send an appeal to an insurance company. Appeal
Limit calculated from DOS.
PCP: Primary Care Physician): PCP is equivalent to the family doctor which refers the patient to
specialist.
Participating Provider (In – Network Provider): Participating provider are those providers who are
having the contract with the insurance company. Contract states that whatever the amount insurance
company allowed to pay provider has to accept that amount.
Non – Participating Provider (Out of network provider) : Those provider who are not having the
contract with the insurance company is called NON Par..
We will bill the balance amount to patient
W9 Form: It is a form send to insurance company for establishing provider credentialed with the
Insurance company W9 form includes providers name, address Tin, SSN, NPI, etc.
This is a fix amount which insurance company has to pay to the provider on monthly
Capitation: basis
Health Care financing administarion
Center for medicare and medicare services
Place of Service: 21 - In Patient When patient admitted in hospital for more than 24 hours is called in
patient.
22 - Out Patient Less than 24 hour
11 - Office Visit
12 - Home Visit
23 - Emergency
13 - Assisted Living
31 - Nursing Facility
32 - Skilled Nursing Facility
CPT:
Anesthesiology - 00100 – 01999, 99100 – 99140
Surgery - 10040 – 69990
Radiology - 70010 – 79999
Pathology and Laboratory - 80048 – 89399
Medicine - 90281 – 99199
Evaluation and Management - 99201 – 99499
CPT code Examples:
Here are some examples:
• 99214 may be used for an office visit
• 99397 may be used for a preventive exam if you are over 65
• 90658 indicates a flu shot
• 90716 may be used for chickenpox vaccine (varicella)
• 12002 may be used when a doctor stitches up a 1-inch cut on your arm
• POS : Point of service
• 11/ 72: 99201 – 99205, 99211 – 99215
12 : 99341 – 99345, 99347 – 99350
13 : 99324 – 99328, 99334 – 99337
21/ 22 : 99221 – 99223, 99231 – 99233
31/ 32 : 99304 – 99306, 99307 – 99310
Modifiers: Modifiers are two digit alpha numeric code that alert the procedure code ( CPT) W/O
changing it.
21 - When provider expends extra time with patient
24 - Post operative period
25 - When provider perform procedure with E&M than use 25 modifiers with E&M code.
26 - When patient gets services outside. Then facility not available in hospital. (Professionals
Services)
50 - Service performed by same operative session (Bilateral Procedure)
59 – Distinct procedural services: Separate the service from others on same day
( Full Form)
SSN - Social Security Number (9 Digits Numeric Number)
HIPAA - Health Insurance Portability and Accountability Act (1996, 21 August, 33 Column)
NPI - National Provider Identifier (10 Digits)
PIN - Provider Identification Number
TIN - Tax Identification Number (9 Digits)
U PIN - Unique Provider Identification Number (5 Digits)
PHI - Protected Health Information
HICN - Health Insurance Claim Number
ICD - International Classification of Diseases (Min 3 & Max 7 Digit Numeric/ Alphanumeric)
CPT - Current Procedure Terminology (5 Digit Numeric/ Alphanumeric)
HCPCS - Healthcare Common Procedural Coding System
MRI - Magnetic Resonance Imagine
CT - Computerized Tomography
COBRA - Consolidated Omnibus Budget Reconciliation Act
The Consolidated Omnibus Budget Reconciliation Act of 1985 is a law passed by the U.S
Government.
By this law, its mandates an insurance program which gives some employees the ability to continue
health insurance coverage after leaving employment.
Medicare ID - SSN + 1 Alpha suffix this is old id
New Medicare id is 10-digit Alfa numeric number.
Medicaid ID - 2 Prefix + 5 Digit + 1 Suffix
What is Medicare supplemental plan: Medigap is Medicare
Supplement Insurance that cover the rest healthcare cost which is not
covered by the Original Medicare and it is sold by private Insurance
companies.
like:
• Co-payments
• Coinsurance
• Deductible
Medicare Supplemental insurance company name: BCBS , Cigna, Aetna, Humana these are the
medicare suplemental insurance .
Website Name: Navinat, Availty,Optum.
Insurance Company name: Medicare, Medicaid, Aetna, BCBS UHC,
Software: Entergy, eCW, (MM 9 Medical Mannager) NextGen
Work/ Job Profile: I was posting the payment through EOB, which was received from insurance
company and I was posting the Auto payment through ERA and end of the day we were preparing the
recon log for the same.
Target for manual posting: 400
Target for Auto Posting: 1200
• Payment posting and Denial Handling received from Insurance Company and patients.
• Working on Entergy, and eCW Billing software
• Managing Payment and Denial records in Excel for data which I posted in software.
Ecw, Ctrix and Nextgen
Why you left your previous company: Because my process has been ram down due to the covidc19.
, So now I am looking better opportunity for carrier growth and financial growth.
Difference between HMO & PPO:
HMO PPO
In HMO plan patient can only go to the In PPO plan patient can go to the participating
Participating Provider (Referral no. is required). provider as well as to the NON-participating
In HMO plan patient first go to the PCP and if providers.
specialist treatment required the PCP refer the In PPO Plan patient can directly go to the
patient to the specialist with the referral no. specialist without a referral from PCP.
What is Revenue Code:
Revenue codes are 4-digit numbers that are used on hospital bills to tell the insurance
companies either where the patient was when they received treatment, or what type of item a
patient might have received as a patient. A medical claim will not be paid if this is missing from
a bill.
Example: A more complex example to use would be something like CPT 12001, which is a simple
laceration repair of a wound on the scalp, the trunk of the body, or the extremities such as hands and
feet. ... It could be done in or as part of another procedure; that would be revenue code 0036.
Out of Pocket Expenses: (Patient pay by his pocket) A medical bill or a part of a medical bill paid by
patient out of his own pocket, because of non-payment of his insurance Company is called an out-of-
pocket expense.
Deductible, Co-insurance, Copay & balance bill are out of pocket expenses.
Subscriber / Beneficiary: A person who parches the policy and pay the premium is called subscriber or
beneficiary.
Forwarding balance: Means that a negative value represents
a balance moving forward to a future payment advice. A positive value represents
a balance being applied from a previous Remittance Advice.
A reference number (the original ICN and the patient's Medicare ID number) is applied
for tracking purposes.
Difference between ICD 9 & 10:
ICD 9
3-5 characters in
length
Approximately 13,000 ICD 10
codes 3 to 7 characters in length
It has limited space to Approximately 68,000 codes are available
adding new code. It has Flexible space to adding new code
Lacks details Very specific
Important Denial codes: we just post the zero payment and forward those case to AR.
CO: 16 described as "Claim/service lacks information or has submission/billing error(s) which is
required for adjudication"
CO:18 described as "Duplicate Claim
CO:22 described as "This service may be covered by another insurance as per COB"
CO:27 describe as Expenses incurred after coverage terminated
CO:29 Described as "TFL has expired".
CO:96 It is for NON covered charges
CO:97 described when "The benefit for this service is included in the payment or allowance for
another service/procedure that has already been adjudicated
CO 144: Incentive adjustment (This group code is used when a contractual agreement between the
payer and payee, or a regulatory requirement, resulted in an adjustment)
CO 187: Health Reimbursement Account, Consumer Spending Account payments (includes
but is not limited to Flexible Spending Account.
Adjustment code:
CO 45: Contractual adjustment.
CO 253 (Sequestration adjustment): It is a 2% of Medicare payment reduction and it kinds of
adjustment.
but some time we need to calculate also we adjust that amount
sequestration stands for “mandatory payment reductions in the Medicare Fee-for-Service
(FFS) program” as per the Budget Control Act of 2011.
Medicare Insurance: It is Nation government insurance and to get the Medicare insurance there are
eligibility criteria.
1st Any us citizen who is 65 years of age or above.
2nd A person suffering from end stage renal disease (ESRD)
3rd A person with permanent disability.
Medicare Part A cover Hospital Billing 1484, Part D Cover both hospital & Physician $445, Part
B Cover Physician Billing $203.
Medicare ID - SSN + 1 Alpha suffix this is old id
New Medicare id is 10-digit Alfa numeric number.
What is Medicaid: It is a state government program to pay the healthcare cast for the people with low-
income group. Medicaid can be the only last insurance of the patient; it can never be the Primary to any
other insurance.
What is Lockbox: Lockbox is a service provided by banks to companies for the receipt
of payment from customers. Under the service, the payments made by customers are
directed to a special post office box instead of going to the company.
WO or Offset : When an insurance make access or incorrect payment on previous
claim they adjust that amount in the next EOB. That is called Offset.
in EOb it shows as WO with claim no. or tracking number
through claim no. or track number
Re-fund: When an insurance company make access or incorrect payment they take
back that amount is called refund. Non Par.
Recoupment: When an insurance company process incorrect EOB, Then they take
back the entire payment, adjustment and PR amount is called the recoupment.
Interview Question:
Ques: If Medicaid paid 0 payment with reason code OA 23 then what action will you
take.
Ans: As a payment poster I will post the denial with reason code and AR team will work
on this. However, no action required since the amount listed as OA-23, Because it is an
allowed amount by the primary payer.
What is EOB and ERA
How many types of refund?
CO 45: Contractual adjustment.
CO 253 (Sequestration adjustment): It is a 2% of Medicare payment reduction and it kinds of
adjustment.
Important Denial codes:
CO: 16 described as "Claim/service lacks information or has submission/billing error(s) which is
required for adjudication"
CO:18 described as "Duplicate Claim
CO:22 described as "This service may be covered by another insurance as per COB"
CO:27 describe as Expenses incurred after coverage terminated
CO:29 Described as "TFL has expired".
CO:96 It is for NON covered charges
CO:97 described when "The benefit for this service is included in the payment or allowance for
another service/procedure that has already been adjudicated
CO 144: Incentive adjustment (This group code is used when a contractual agreement between the
payer and payee, or a regulatory requirement, resulted in an adjustment)
CO 187: Health Reimbursement Account, Consumer Spending Account payments (includes
but is not limited to Flexible Spending Account.
Super Bill: Super Bill is a form listing procedures, service and diagnosis codes used to record
services performed for the patient and the patient’s diagnosis for a given visit.
Once the charges entry process completed, we proceed to create the claim which will be submitted to
the insurance companies through paper or electronic (thru clearing house) for reimbursement.
Authorization#: Authorization number also known as prior authorization number or pre certification
number. Provider has to take an approval from the insurance company before the patient receives the
health care services in order for claim submitted get reimbursed. It relates not only whether a health
care services of the procedure is covered but also to find whether the health care services is medically
necessary.
Day Activity Payment: First my team lead assign the batches and we just start
posting those batches in system and for manual posting we open the EOB and
first we just create the batch and open first account in system and we just need
to match patient name and date of service, CPT if all details match then we just
post those payment in system. End of the day we prepare the recon sheet and
mention all the posted batch details in that sheet.
> First we check what is the total amount posted if check match then
reconcilation not require if not match then we do the reconcilation.
for ERA reconcilation we generate the system report and match with remitace
once we found the missing payment then apply that amount mannualy and
reconciled the check.
• ERA : post karne ke liye hame ERA file system me milti hain aur ham
usko run karate the uske bad ham run file ko review karthe the to
verify that every thing posted correctlt or not.
2000 check manual: Main batch create karugi aur uske bad one by one patint
system open karke posting karenge . last me ham check ko reconcile karthe the
aga pura check reconcile ho jata tha that means we did not miss any thing.
Agar missing payment hoti hai to phir ham system report generate karthe hain
to indemnitfy that missing payment.
If check not reconcile hain then Agar check reconcile hain that means we did not
miss any thing and if not rencile that mean
Batch se pata lag jata tha ki jitney $ ka check hain o pura post hai ya nahi
CO 144
C0 187
CO: 16 described as " Missing Information
CO:18 described as "Duplicate Claim
CO:22 described as " Not covered services.
CO:27 describe as Expenses incurred after coverage terminated
CO:29 Described as "TFL has expired".
CO:96 It is for NON covered charges
CO:97 described when "The benefit for this service is included in the payment or
allowance for another service/procedure that has already been adjudicated
