Medical Billing – Med Sol Tech, LLC

Manual Contents:
1) Chapter – 1 (Introduction)
a. What is Medical Billing
b. Role and function of medical billing company
c. Parties in Medical Billing
d. What is Health Insurance
e. Types of Health Insurance Coverage
f. Govt Institutes involved in Medical Billing Process (CMS, AMA,
HIPPA Act)

2) Chapter – 2 (Medical Billing Cycle)

a. Complete Flow Chart of Medical Billing process.
b. Different departments involved in medical billing process.

3) Chapter – 3 (Data Entry & Coding Department)

a. Appointment
b. Visit Date and Demographic
c. Check-Up
d. Medical Transcription
e. Super Bill
f. Coding of Bills, Demo & Charges Entry
g. Verification of Bills and Submission

4) Chapter – 4 (Insurance AR & Patient AR)

a. Rejections
b. Denials
c. Payments
d. Aging Follow Up (Insurance / Patient)
5) Chapter – 5 (Medical Terminologies)

6) Chapter – 6 (CPTs, ICD, Modifiers, Billing Abbreviation)

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Chapter – One (Introduction)
Overview:
Gone are the days when the physician used to accept entire amount due from all the patients directly
and immediately after the services was rendered. In those days medical expenses was affordable. But
it is a different scenario now. Costs of medical expenses are so high that a normal middle-class people
will not be able to afford the entire cost of medical expense. Here is where the insurance company
comes into picture.

When patient takes policies with a health insurance company, the insurance takes the responsibility
of all the financial risks undergone by the patient in relation to medical treatment for himself or is
dependents during the tenure of the policy. Since insurance companies carry financial risks, they are
also referred as carriers.

What is Medical Billing:

As discussed above, the physician does not get paid for his services immediately after they are
rendered. Majority of the patients has insurance coverage and details of such coverage are provided
to the physician before treatment. It is the responsibility of the physician to submit claims to the
insurance company and get paid for his services. Submitting claims and getting paid is not as simple
as it looks. It is a lengthy process and involves a lot of rules and regulations, systems and is very
complicated. The physician cannot provide his entire attention to this activity. Hence the concept of
Medical Billing arises.

Role and Function of Medical Billing Companies

Physicians appoint Medical Billing Companies to take care of their billing. The Medical Billing
Companies should clearly spell out their duties and responsibilities in their agreement with the
physician. The main objective of the Billing Company is to maximize the collections.
The main function of a Medical Billing company is to help healthcare providers and organizations
process patient/client information in order to get paid on time. The term "healthcare providers"
means Physicians, Psychotherapists, Psychiatrists, Chiropractors, Nursing Practitioners, Dentist,
Medical Social Workers, Physical Therapists, Occupational or Speech Therapists. It also includes
healthcare businesses such as: Ambulatory Services, Durable Medical Equipment Suppliers, Medical
and Surgical Suppliers, Medical Laboratories and Clinics. And organizations such as Nursing
Homes, Home Health Care Agencies, Rehabilitation Centers, Hospice Care Centers, and Hospitals.

Claims filing to private insurance companies and government sponsored programs such as Medicare
and Medicaid consist of the main business of a Medical Billing Service Company. However, we
cannot ignore the importance of good record keeping - medical and otherwise to justify why we bill
for whatever condition. Also, part of Medical Billing company's job is to make sure clients maintain
compliance with whatever government rules and regulations there are.

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Parties in Medical Billing:
There are three parties in Medical Billing Process. The PHYSICIAN, The INSURANCE
COMPANY and the PATIENT. The Physician in order to attain his objective both should comply
with the rules and regulations given out by various insurance companies in submitting claims and at
the same time does not penalize the patient.

WHAT IS HEALTH INSURANCE?

The dictionary defines Insurance as: “Protection against risk, loss or ruin by a contract in which an
insurer (the insurance company) guarantees to pay a sum of money to the insured (you) in the event
of some contingency (a random occurrence) such as an accident, a death, or illness, in return for the
payment of a premium”. Among the many types of insurance are health, disability, liability,
malpractice, property, auto and life insurance.

Health Care Insurance is a contract between a policyholder* and an insurance carrier (or government
program) to reimburse the policyholder for all or a portion of the cost of medically necessary
treatment rendered by health care professionals. In some policies the contract can include preventive
care as well as medically necessary treatment.

As a medical biller, you need to recognize the various ways in which a patient may obtain health
insurance coverage. There are three way a person may obtain health insurance coverage:

1. Group Health Plan: a plan arranged by an employer or special interest group for the
benefit of members and their eligible dependents. This plan provides maximum
benefit packages based on desired coverage and cost factors. Group policies are often
benefits of employment that are provided by the employer with little or no cost to the
insured (employee).

2. Individual: a plan issued to an individual. This type of coverage has a high premium with
benefits based on the needs and financial factors of the individual policyholder.

3. Government programs are designed to provide benefits and health care for individuals who
would not otherwise be able to afford them. These programs are Medicare, Medicaid, and
CHAMPUS programs.

Health insurance was designed to assist the patient with the expenses incurred for medical treatment.
The insurance company did not design their policies to alleviate the patient of the financial burden
of medical care. The carrier cannot be expected to provide reimbursement for which coverage has
not been purchased. This refers to a benefit that is not in the contract, such as an individual who
purchases a policy with only hospital coverage, the carrier cannot be expected to reimburse the
physician’s charges.

TYPES OF HEALTH INSURANCE COVERAGE

The major types of health insurance coverage fall neatly into seven categories: Commercial, Blue
Cross and Blue Shield, Medicare, CHAMPUS, Medicaid, Worker’s Compensation and Health
Maintenance Organizations (HMOs). This is not to say that the following seven health insurance
types are the only types of insurance coverage.

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 COMMERCIAL CARRIER: Commercial carriers offer contracts to individuals and
groups, mostly groups, under which payments are made to the beneficiary (or to the providers
if they have accepted assignment of benefits) according to a fee schedule of benefits for medical
services. It should be noted that not every service is covered under commercial plans; each one
has its own benefits and exclusions. i-e Aetna, UHC, Cigna,
Health Choice etc

 GOVT. INSURANCES: These insurances are funded by state governments, and following
are the 4 categories of Govt insurances.

1. Medicare
2. Medicaid
3. Tricare
4. RR Medicare (RR-Railroad)

1) Medicare:
Administrated by directly federal government and applicable for
1) People 65 Years above
2) People Under 65 with certain Disabilities
3) For People with Disabilities and Illnesses

Medicare has four parts:

Part A (Hospital Insurance) Only Covered with Hospital Services. ( Ex. Bed
Charges & Equipment charges) Its Cover Inpatient care in Hospital. It’s cover
Skilled Nursing facility, hospice, and home health care. Claims billing to UB92 &
B04 forms.

Part B (Medical Insurance) It is Covered with Doctors or Professional Services, hospital

outpatient care, Office Visits and home health care. Its cover some Preventive services to help
maintain your health and to keep certain illness from getting worse, HCFA-1500& CMS1500 forms
are used to bill claims.

Part C (Medicare Advantage) A Medicare Advantage Plan (like an HMO or PPO) is another
Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes
called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare
pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans.
These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can
charge different out-of-pocket costs.

Part D (Medicare prescription Drug Coverage)

Only Covered with Drug Programmed (supply for Medicine) Ex: Sugar Patient.

2. Medicaid: This is health care assistance program administered jointly by the federal and state
governments. Each state sets up and operates its own program within the general guidelines set down
by the federal government. This is not an insurance program. It is a state funded assistance program.
Eligibility is month-to-month and based on the income of the recipient.

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3. Tricare: TRICARE is the uniformed services health care program for active-duty service
members (ADSMs), active-duty family members (ADFMs), National Guard and Reserve members
and their family members, retirees and retiree family members, survivors, and certain former spouses

4. Railroad Medicare: The Federal Medicare program provides hospital and medical insurance
protection for railroad. retirement annuitants and their families, just as it does for social security
beneficiaries.

Govt Institutes involved in Health Insurance and Medical Billing Process:

CMS: The Centers for Medicare & Medicaid Services (CMS), is a federal agency within
the United States Department of Health and Human Services (HHS) that administers
the Medicare program and works in partnership with state governments to administer Medicaid,
the Children's Health Insurance Program (CHIP), and health insurance standards.

AMA: The American Medical Association (AMA) is a professional ssociation and lobbying
group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois.
The AMA's stated mission is "to promote the art and science of medicine and the betterment of
public health.

HIPAA Act: The Health Insurance Portability and Accountability Act of 1996, It modernized the
flow of healthcare information, stipulates how personally identifiable information maintained by the
healthcare and healthcare insurance industries should be protected from fraud and theft, and
addressed some limitations on healthcare insurance coverage. It generally prohibits healthcare
providers and healthcare businesses, called covered entities, from disclosing protected information to
anyone other than a patient and the patient's authorized representatives without their consent.

The act consists of five titles. Title I of HIPAA protects health insurance coverage for workers and
their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative
Simplification (AS) provisions, requires the establishment of national standards for electronic health
care transactions and national identifiers for providers, health insurance plans, and employers. Title
III sets guidelines for pre-tax medical spending accounts, Title IV sets guidelines for group health
plans, and Title V governs company-owned life insurance policies.

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Chapter – Two (Billing Cycle)
a. RCM:
Revenue cycle management could be challenging to manage. However, when the proper steps are
followed diligently, one can receive on-time reimbursements and boost profitability. If you are a
novice to medical billing and collections, this Revenue Cycle Management Flowchart would be
handy.

Step 1: Appointment or Scheduling - The patients' healthcare organization or clinic is

contacted for patient appointment with the healthcare provider. Some clinics choose to schedule
appointments using an advanced software application, whereas a few prefer to manually.
Step 2: Records Patients Detail - When a patient consults a healthcare provider, details of the
condition and service rendered are recorded either by audio or video. These may be recorded in
front of the patient or after the encounter. This gives a clear idea of the conditions and
medications that the doctor has prescribed. Subsequently, the record is forwarded to process
medical billing and claim revenue which is maintained in the healthcare CRM system.

Step 3: Medical Transcription - The recorded audio/video is then transferred into a medical
script. The script contains the complete condition of the health record. This process of
transferring voice/video medical reports by healthcare providers is known as medical
transcription. But why is it important? Maintaining a formatted and edited file is essential. It
must be ensured that the transcription does not hold any false or wrong data, as it might put the
patient’s health at risk.

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Step 4: Demographics / Eligibility Verification - Once data is collected, the medical billing
team verifies the patient’s data. The team first focuses on policy benefits and verifies the
eligibility. This gives them a clear idea of the insurance claim can be obtained for the services
rendered or not. Once they get an idea, they check on patient responsibilities such as co-pay,
deductible out of the packet, and if the patient has accumulated the expenses. For certain
services, prior authorization is needed from the insurance company. If the said insurance
company gives a heads up, the service is ready to be provided. The hospital staff can verify data
using medical billing software to speed up the work.

Step 5: Medical Coding - Once the medical file is checked thoroughly, the transcript
information is converted into medical codes. Reading and analyzing the patient’s complete
medical history can be a cumbersome process, so the info is scripted into codes. Only licensed
practitioners are involved in the process. These professionals have extensive experience in
medical coding and rely on DX (condition of the patient) and CPT (service rendered to the
patient) to transcript patient records into medical codes.

Step 5: Charge Entry - After converting the data into medical codes, the charges for the
services are entered in the main patient record. This is done before making claims from the
insurance company. The charges entered are claimed by the medical billing company with
insurance for reimbursement. For easy revenue claims, it must be assured that there are no
erroneous entries.

Step 5: Charges / Claims Transmission - Once the charges are entered, verification was done
on these claims before submitting to insurances. If now errors are found the claims are
transmitted to payer by three means:
a. Paper Claim Submission
b. EDI Claim Submission
c. Online / Payer portal Submission
d. Claims submitted to payer by fax number.

Step 6: AR Follow-up - The role of an accounts receivable (AR) caller is very important in
any medical billing process. They concentrate on lower denials and increase payment flow. AR
specialist is responsible to work on unpaid claims by insurance or by patient.

Step 6: Denials Management - Another important step in the medical billing process is
denial management. It facilitates profitable revenue growth and reduces rejections from
insurance companies. The process involves addressing denied claims and maintaining constant
follow-ups. The denial management team needs to take appropriate actions to decrease denials
and increase the frequency of payments. So, how can this be achieved? Each denied claim should
be analyzed and researched, and the whole process should be accelerated to ensure maximum
reimbursements.

Step 6: Payments Posting - The final step in the medical billing process is to post
payments to the patients. The posting team whether it is from Insurance AR or Patient AR,

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records denials and payments and post them into patient account which is maintain in practice
mate. They are also responsible for sending explanations of benefits, correspondence, and
electronic remittance advice to patients. Moreover, the team needs to match bulk payment
receivables and tally them with the cheque amount.

b. Departments in Billing Cycle:

Following department are actively works in medical billing process:

I. Data Entry and Coding Department

II. Quality Assurance department
III. Insurance AR Department
IV. Patient AR Department
V. Payments Posting Department

Chapter – Three (Data Entry and Coding Department)

The data entry team is responsible for handling appointments and visit super bills. When the
doctor renders medical services to any patient it is the doctor’s office manager’s job to send all
super bills to the medical billing team. We have one specific web base software which is secure.
“Ebridge” for this purpose. At the day end all super bills and demographic are uploaded on
ebridge by doctor office and then it is retrieved by data entry team for billing purpose.
Following are the steps the date entry team work on to submit any claim to insurance:

1- Ebridge: Data entry team downloads the superbills batches and demographic sheets
from ebridge daily and saves them in proper file cabinet.

2- Demo-Entry: In the next step data entry team will enter patient personal and insurance
information in a billing software.

3- Coding: In this step the Data entry team will decode the procedure codes according
to service level or time and create and proper excel file in a given format.

4- Charge Entry: In this step data entry team will enter all claim from excel file to
billing software (Health fusion / Office ally).

5- Verification: In this step data entry members will recheck all entered claims and match
them with raw data which is received from doctor office.

6- Submission: If the data entry team found no errors in entered claims, then they will
release all claim at once.

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What doctor send us on super bill: On super bill he writes the patient’s
name, DOB, Insurance, marked CPT codes and write down the diagnoses, attached
is the example of super bill:

Following are the POS codes we are using for billing inpatient/outpatient
emergency hospital, Clinic, Home health, telemedicine etc.

POS Codes: Description POS Codes: Description

2 Telehealth Services 22 Outpatient Hospital
11 Office/Clinic services 23 Emergency Room
12 Home Health Services 24 Ambulatory Services
20 Urgent Care Facility 31 Skilled Nursing Facility
21 Inpatient Hospital

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CPT Codes:
 Evalua on and Management: 99201 – 99499
 Anesthesia: 00100 – 01999; 99100 – 99140
 Surgery: 10021 – 69990
 Radiology: 70010 – 79999
 Pathology and Laboratory: 80047 – 89398
 Medicine: 90281 – 99199; 99500 – 99607

Office E&M Codes: POS 11

New Patients CPT Established Patients CPT
99202 20 Min 99211 5 Min
99203 30 Min 99212 10 Min
99204 45 Min 99213 15 Min
99205 60 Min 99214 25 Min
99215 40 Min
Hospital & Other Visits: POS: 21
99222 Admission - 55 Min 99291 ICU - 30 to 70 Min
99232 Follow Up - 25 Min 99292 ICU - Admit (100 Min)
99233 Follow Up - 35 Min
99238 Discharge - 30 Min
99239 Discharge - >30 Min

Annual Physical Exams Codes:

Physical Exam (ICD:

Z0001)
New Patients Established Patients
Commercial Ins Patient Age Commercial Ins.
99381 1 Year + 99391
99382 (1-4) 99392
99383 (05-11) 99393
99384 (12-17) 99394
99385 (18-39) 99395
99386 (40-64) 99396
99387 65 + 99397
For Govt For Govt Insurances
G0402 in 1st 12 month
and G0438 for New
Patient G0439

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Chapter – Four (Insurance and Patient AR Department)

I. Aging Follow Up (Insurance AR)

Rejections:
Rejection occurs: A claim rejection occurs before the claim is processed and most often results
from incorrect data.
Rejections v Denial
Denial: a claim denial applies to a claim that has been processed and found to be unpayable.
Rejection can be carried out by HF or by payer’s clearinghouse (Scrubbing)

Most common types of rejection are listed Below:

Sr# Rejection Types Type of rejection
Subscriber and subscriber id not Payer rejection
1
found/invalid insurance ID
2 Valid referral required (VA) Payer rejection

5 Invalid D-O-B Payer rejection

6 Invalid D-O-S Payer rejection

7 Invalid diagnosis codes HF Rejection

9 Incorrect Place of Service Payer rejection

10 Policy Cancelled Payer rejection

11 The service date cannot be a future date HF rejection

13 BCBS & Medicare Billing NPI Payer rejection

14 Secondary Claim don’t accept electronically Payer rejection

15 Invalid Admin code Payer rejection

Modifier missing telehealth claims (95 Payer rejection
16
modifier)

Rejections and corresponding Remedies:

 Subscriber and subscriber id not found/invalid insurance ID/Policy Cancelled:
Steps that must keep in mind while resolving:
1. Verify Patient’s Demo (if there is any other insurance apart from Rejected payer)
2. Verify Rejected payer eligibility via portal, real time or call.

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3. Verify E.H.R, E-bridge and other available resources.
4. Send a Face sheet request if patient visited the hospital on the mentioned dates, or
send the request to the doctor’s office, in case the patient has visited the office, to
get the updated details
5. If we do not get anything from hospital or office Send Patient Call to patient AR
Dept.
6. If we are unable to get any details transfer the balance to the patient with proper
notes.
 Valid referral required (VA):
VA Rejected the claim if we do not add 12 Digit Authorization # in the claim.
1. Call VA Optum and get the authorization number for the requested range of date
also ask them where we need to send the claim(s) (get correct payer ID).
2. Update authorization number and corrected payer ID in demo along with the
dates.
3. Submit the claim by adding VA authorization/Referral number.

 Invalid D-O-B:
Sometimes the patient’s DOB doesn’t match with insurance Records in this case
following steps are to be followed.
1. Send Account details to DE dept (maybe we submit claims to incorrect patient
chart)
2. If the Patient chart is correct then verify patient details and add correct DOB, then
verify eligibility of the payer and re-submit the claim.

 Invalid D-O-S/ The service date cannot be a future date:

We received HF rejection from our clearing house if by any means we put future
DOS in our claim or use invalid Date format. Please verify each service line item
for the claim and identify the error and rectify the issue.

 BCBS & Medicare Billing NPI:

Medicare and BCBS only accept Group Billing NPI for claim submission. If by
any means, we put Provider Individual NPI our claim will get rejected. Edit claim
and enter Group NPI and re-submit the claim.

 Secondary Claims, sometimes, do not get accepted electronically:

While creating COB some payers do not Accept claims electronically, they only
accept Medicare’s crossover claims. In this case verify Medicare’s ERA, if
Medicare cross overs the claim to the secondary insurance, edit Secondary claim
and re-submit it as “cross-over”.
 Invalid Vaccine Admin code:
Medicare and commercial insurance have different Admins for Vaccines.
1. Medicare and Medicare HMO/PPO plans only cover CPT G0008 and
G0009.

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2. Commercial only covers CPT 90471.

 Incorrect Place of Service/ Modifier missing telehealth claims (95 modifier):

1. For commercial payers Telemedicine claims must be submitted with Place
of service 02 along with modifier 95. Violation of guideline will result in
claim rejection.
2. For Medicare, claims must be submitted with POS 11 along with 95
modifiers for telemedicine.

Denials and Remedies

Definition: The refusal of an insurance company or carrier to honor a request by an individual (or
his or her provider) to pay for healthcare services obtained from a healthcare professional.

 In-active policy (CO 27):

Steps we must Follow while working on this kind of denial.
1. Check eligibility for the denied insurance. (IF patient is inactive then…)
2. See whether there is any other insurance(s) in Demo. (IF NO then…)
3. Verify Eligibility from Medicaid(portal), UHC (real-time), Aetna(real-time) by using name
and DOB (IF not then….)
4. Verify from Hospital (if patient visited the hospital) OR Office (EHR, e-bridge) IF they
have same details then…
5. Send Patient call to patient AR to get active coverage details. (IF patient was not reachable
then….)
6. The patient is liable for the charges, and now we can bill to patient.

 Missing or incorrect information (CO 15):

Due to wrong authorization/referral number, wrong name for instance, Smith Jr, Albert is inserted
as Smith, Albert. Similarly, claims also get denied on account of wrong DOB or Insured ID.
1. Check eligibility with denied insurance. In this case following steps need to be followed
2. Verify details from face-sheet/Insurance card.
3. If claim denied due to invalid CPT or ICD. Verify Billing guideline for them and then re-
bill.

 Not covered by this payer (CO 22):

While submitting the claim sometimes we send claim to incorrect insurance. Typically, we have
received this kind of denial from Medicare. In this case we may:
1. Check Medicare’s eligibility from Realtime.
2. Check if Patient has Medicare HMO/PPO plan.
3. If YES, then check the correct payer details by reading Medicare’s eligibility (coordination
of benefits). From there we can get Respective PPO/HMO plan details
4. Update Correct payer in demo and re-submit the claim.
If we receive this kind of denial from commercial payer, in this case mostly we have submitted the
claim to secondary insurance. Please check primary insurance from all available resources update
it and re-submit the claim to correct insurance after verifying eligibility.

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 Timely filling Denial (CO 29):

Occurs If Claim is not submitted within the timeframe as specified by each payer. Some
payers allow 90 days for a claim to be filed, while others allow as much as a year. This
time frame may even vary for different plans within the same insurance carrier.
In order to get the claim paid, we file an appeal and attach a supporting document and
fax/mail/ or submit it online the insurance for reconsiderations. If we do not have any
supporting documentation, we need to write off the balance, it’s a provider Write off.

If Medicare part B is inactive: Check eligibility first, then transfer insurance balance to
patient responsibility, create COB and send claim to secondary insurance.
Check secondary insurance eligibility, create COB submit claim to secondary.

 LCD (Local coverage determination) (CO 167):

Service was denied because medical necessity was not documented. This is because that
item or service isn't considered reasonable and necessary for the diagnosis or treatment of
illness or injury, or to improve the function of a malformed part of the body.
Improper CPT or ICD-10 codes: The code must correspond to the diagnosis, or it can be
denied.
We need to get correct Diagnosis as per LCD policy. We can review latest LCD guidelines
from this link:

Link: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/LcdSearch

 CCI (Correct coding initiative) (CO 16)

Incorrect HCPCS code
CPT code is inconsistent and not billable.
CPT code combination are not billable.
I.e., if you bill 99386 and 99387 both are CPT code for physical examination, payer will deny one
of it.
 Out of network.
A lot of patients have plans that require doctors and practitioners to be “in network” for
coverage.
For out of network providers patient need to get prior authorization from insurance (according
to plan)

Aging and follow up (insurance/patient)

The Accounts Receivable Aging Report indicates how long insurance claims and patient balances
have been outstanding. The lower the Balance, the better. It’s represented in a dollar amount. Our
report example provided is broken out into the following buckets: 0-30 days, 31-60 days, 61-90
days, 91-120 days, >120 days plus. The Accounts that are in 120 -180+ bucket is the most crucial
accounts, and we need to Follow up on them in immediate basis.

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Follow up is the process of looking after denied claims and reopening them to receive maximum
reimbursement from the insurance companies.

The 0–30-day bucket for both the patient and insurance should be your highest
totals. They’re the most current – we just submitted the claims and we’re waiting for a lot of that
money.

Your next highest will be the 31–60-day totals. Typically, most of the claims due will fall in
the 0–60-day period.

The money in the 61-90 bucket should drop off dramatically, especially with your insurance
balances. You can see in the example I’ve given here that our insurance percentage for 61-90
days has dropped to 7.3% of the total outstanding insurance balances.

The 91–120-day bucket totals should drop as we work claims, bill patients, do our follow-up
and pursue collection efforts, by running this report once a month, you can watch your progress.

Keep your percentage of 121 days or more to a minimum. Make it your goal to work these
old claims hard. The older the claim the more difficult it is to collect on. The aim is to keep it in
the single-digit percentages for over 120 days.

Insurance reports should always be run by the date of service. This will give you a true
accounting of how long the insurance takes to be paid.

One last thing you’ll see in the report is a breakdown of the individual insurance
companies. This gives you a good indication of which insurance company owes the practice the
most money and which companies your practice should focus on to recover unpaid or denied
claims.

Issues, Status and Actions:

 Claim not on file:
Call insurance and Verify Claims Payer ID for electronic submission.
Fax #
Whose attention the claim must be faxed.
Effective date
Timely filing period
Verify id and group #.

 Claim in process.

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May I have the claims mailing address?
Could you please give me the fax # and can I go ahead and fax it your attention?
Is patient eligible for the DOS?
May I have the filing limit for this claim?

 If Claim in process, we need to get the following information:

Claim number.
Processing time.
Can I have the date on which the claim was received?
How long would that take to process this claim?

 If you called to insurance for claim status and Claim got paid:
Received date.
Process date
Check #
Check date.
Paid amount.
Allowed amount.
Patient's responsibility
Write off(adjustment)
Pay to address.
Cashed date.
Could you please tell me the check # and check date?
How much was the allowed amount for the claim.
Can you please tell me how much was paid for this DOS?
Is there any write-off on this claim?
What would be a patient’s responsibility?
Can you verify the pay to address for me please?
Was the check cashed?

 If Claim is paid to wrong address, verify pay to address:

Telephone appeal to update W9 form
Cancelled check copy if cashed.
If not, request for stop payment and reissue the check.
Could you verify the pay to address for me please?
Can you go ahead and update your records if I give you the correct pay to address for us?

 Claim denied for Authorization (CO 15):

Date of denial
Check if there is any auth in the software mentioned for the dos.
Check if they have an auth on file for any hospital claim for the same dos.
Fax number
EOB request.
May I have the date this claim was denied?
Could you please tell me if you see any authorization # for the same DOS for the hospital
claim?

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I have a authorization # in the system, could you re-process the claim if I give this number to
you now?
Would you be able to re-process this claim if I were to fax you the claim with?
authorization number?
Could you fax / mail me a copy of the EOB?

 Claim denied for eligibility (CO 27):

Effective/ termination date of coverage
EOB request
May I have the denial date for this claim?
May I have the effective / termination date of patient’s policy?
Could you please fax / mail me a copy of the EOB.

 Claim denied for non-covered services

Date of denial
Details of the non-covered service
Check if patient can be billed
EOB request.
May I have the denial date for this claim?
Could you please tell me the services that are not covered under this plan?
Can we go ahead and bill the patient for this claim?
Can I get a copy of this EOB faxed / mailed to me please?
Claim denied for EOB from the primary insurance

 Claim paid to patient

Check if provider is participating
Payment details
EOB request.
May I know when was the claim paid to patient?
Can I know how much was paid to the patient?
Is the provider participating? Could you fax / mail me a copy of the EOB?

 Claim denied for pre-existing condition

Date of denial
Pre-existing condition
EOB request
May I have the date this claim was denied?
Could you tell me the condition that was classified as pre-existing for this patient? Could you
fax/mail me a copy of the EOB?

 Claim denied as not medically necessary

Date of denial
Appeal with medical notes
Fax number
EOB request
May I have the date this claim was denied?

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Can I go ahead and send the appeal with medical notes?
Can I have your fax number please?
Could you fax/ mail me a copy of the EOB?

 Claim denied for referral.

Take Date of denial
Check if there is any referral for the software mentioned for the dos.
Check if the provider is participating.
Take Fax number.
Ask for EOB.
I have a referral # in the system, can you please re-process the claim if I give this number to
you now?
Would you be able to re-process this claim if I were to fax you the claim with referral.

II. Aging Follow ups. (Patient AR)

Patient Billing:
Patient billing is the process of acknowledging patient’s through BRC which is referred as balance
reminder call usually making a call on prior basis or after transmitting the statement and finally receiving
the payment from the patients.
Also, there is a term of dormant balance usually refers as bad debts which means patient doesn’t pay
his account balance for a specific time period then account will be consider as bad Debt. For this sort of
accounts provider has to make the decision either to write off the balance or move to collection agency.

Patient Aging:
Patient aging means those balances which lies in the patient responsibility or those balances which patient
is accountable to paid for.

Types of Patient responsibility:

Patient responsibility has following major Types:

 Self-Pay Patient Co-insurance Major Insurance Denials

 Deductibles Copay

1: Self-pay Patients:
Self-pay patients refer to those patients who have no insurance coverages and have to pay by themselves.

2: Deductibles:

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The amount patient pay for covered health care services before insurance plan starts to pay.
for example, Patient pays the first $1,00 of covered services and rest 80% will be paid by the insurance.

3: Co-insurance:
The percentage amount the primary insurance leaves for patient or Sec ins are called Co-insurance. Such
as the primary pays 80% and the rest of 20% will be paid by sec the insurance or patient.

4: Copay:
The amount of money that a patient with health insurance pays for each healthcare service,
The amount of the copay usually depends on the type of healthcare service. Also called copayment.

5: Major insurance Denials:

Denials means when an insurance company decides not to pay for services or products they have agreed
to cover.

Various factors that may cause of denials and occur patient responsibility:
 Inactive coverage
a) Expense incurred prior to the coverage.
b) Expense incurred after coverage termination.
c) Ineligible services
 Coordination of benefits issue
 The patient is not eligible for care delivered by the insurance plan.
 Out of network providers
 None covered charges.

Patient Aging and follow ups Cycle:

Patient AR Aging and follow ups include following steps:
 After insurance finalized the claims if they process any patient responsibility the amount will occur in
patient bucket.
 Patient AR team will run the patient aging report on monthly basis and will filter the workable
accounts.
 After adding patient’s complete details to the daily sheets patient AR team will analyze each account
and will identify the type of patient responsibility.
 After proper analysis patient AR team will make a call to the patient to let the patient know about
outstanding balance and explains the reason why He / She owes the balance.
 After the patient agrees the Patient AR team will create the statements.
 Moreover, the patient AR team will transmit the invoices.
 Additionally, AR team will follow ups on the statements which have been transmitted.

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 And finally Patient AR team will collect the payment and update in the system.

Sending Statements

Following Up

Collecting Payments

Aging Report

Prior Acknowledgment or BRC

Creating Itemized Statements

Types of patient payments:

Patients’ payments have some major types which are listed below:
 Checks payments.
 Credit card payments
 Electronic fund transfer
 Money order
 Bank Draft

Chapter – Five (Medical Terminologies)

AMA - American Medical Association. The AMA is the largest association of doctors in
the United States. They publish the Journal of American Medical Association which is
one of the most widely circulated medical journals in the world.

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Aging - One of the medical billing terms referring to the unpaid insurance claims or patient
balances that are due past 30 days. Most medical billing software's have the ability to generate
a separate report for insurance aging and patient aging. These reports typically list balances
by 30, 60, 90, and 120 day increments.

Ancillary Services - These are typically servicing a patient requires in a hospital setting that
are in addition to room and board accommodations - such as surgery, tests, counseling,
therapy, etc.

Appeal - When an insurance plan does not pay for treatment, an appeal (either by the provider
or patient) is the process of objecting this decision. The insurer may require documentation
when processing an appeal and typically has a formal policy or process established for
submitting an appeal. Many times the process and associated forms can be found on the
insurance providers web site.

Applied to Deductible - You typically see these medical billing terms on the patient
statement. This is the amount of the charges, determined by the patients insurance plan, the
patient owes the provider. Many plans have a maximum annual deductible that once met is
then covered by the insurance provider.

Assignment of Benefits - Insurance payments that are paid to the doctor or hospital for a
patient's treatment.
Beneficiary - Person or persons covered by the health insurance plan.

Blue Cross Blue Shield (BCBS) - An organization of affiliated insurance companies

(approximately 450), independent of the association (and each other), that offer insurance plans
within local regions under one or both of the association's brands (Blue Cross or Blue Shield).
Many local BCBS associations are nonprofit BCBS sometimes acts as administrators of
Medicare in many states or regions.

Capitation - A fixed payment paid per patient enrolled over a defined period of
time, paid to a health plan or provider. This covers the costs associated with the patient's health
care services. This payment is not affected by the type or number of services provided.

CHAMPUS - Civilian Health and Medical Program of the Uniformed Services. Recently
renamed TRICARE. This is federal health insurance for active duty military, National
Guard and Reserve, retirees, their families, and survivors.

Charity Care - When medical care is provided at no cost or at reduced cost to a patient that
cannot afford to pay.

Clean Claim - Medical billing term for a complete submitted insurance claim that has all the
necessary correct information without any omissions or mistakes that allows it to be processed
and paid promptly.

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Clearinghouse - This is a service that transmits claims to insurance 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 easily corrected. Clearinghouses
electronically transmit claim information that is compliant with the strict HIPAA standards
(this is one of the medical billing terms we see a lot more of lately).

CMS - Centers for Medicaid and Medicare Services. Federal agency which administers
Medicare, Medicaid, HIPAA, and other health programs. Formerly known as the HCFA
(Health Care Financing Administration). You'll notice that CMS it the source of a lot of
medical billing terms.

CMS 1500 - Medical claim form established by CMS to submit paper claims to Medicare
and Medicaid. Most commercial insurance carriers also require paper claims be submitted on
CMS-1500's. The form is distinguished by it's red ink.

Coding - Medical Billing Coding involves taking the doctor's notes from a patient visit and
translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment.

COBRA Insurance - This is health insurance coverage available to an individual and their
dependents after becoming unemployed - either voluntary or involuntary termination of
employment for reasons other than gross misconduct. Because it does not typically receive
company matching, It's typically more expensive than insurance the cost when employed but
does benefit from the savings of being part of a group plan. Employers must extend COBRA
coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget
Reconciliation Act which was passed by Congress in 1986.

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain
conditions extend up to 36 months.

Coinsurance - Percentage or amount defined in the insurance plan for which the patient is
responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance
carrier pays 80% and the patient pays 20%.

Collection Ratio - This is in reference to the providers accounts receivable. It's the ratio of
the payments received to the total amount of money owed on the provider's accounts.

Contractual Adjustment - The amount of charges a provider or hospital agrees to write off
and not charge the patient per the contract terms with the insurance company.

Coordination of Benefits - When a patient is covered by more than one insurance plan.
One insurance carrier is designated as the primary carrier and the other as secondary.

Co-Pay - Amount paid by patient at each visit as defined by the insured plan.

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CPT Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a
procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code.
Established by the American Medical Association. This is one of the medical billing terms we
use a lot.

Credentialing - This is an application process for a provider to participate with an

insurance carrier. Many carriers now request credentialing through CAQH. CAQH
credentialing process is a universal system now accepted by insurance company networks.

Credit Balance - The balance that's shown in the "Balance" or "Amount Due" column of
your account statement with a minus sign after the amount (for example $50-). It may also
be shown in parenthesis; ($50). The provider may owe the patient a refund.

Crossover claim - When claim information is automatically sent from Medicare the
secondary insurance such as Medicaid.

Date of Service (DOS) - Date that health care services were provided.
Deductible - amount patient must pay before insurance coverage begins. For example, a
patient could have a $1000 deductible per year before their health insurance will begin
paying. This could take several doctor's visits or prescriptions to reach the deductible.

Demographics - Physical characteristics of a patient such as age, sex, address, etc. necessary
for filing a claim.

DME - Durable Medical Equipment - Medical supplies such as wheelchairs, oxygen,

catheter, glucose monitors, crutches, walkers, etc.

DOB - Abbreviation for Date of Birth

Duplicate Coverage Inquiry (DCI) - Request by an insurance company or group medical plan
by another insurance company or medical plan to determine if other coverage exists.

Dx - Abbreviation for diagnosis code (ICD-9 or ICD-10 code).

Electronic Claim - Claim information is sent electronically from the billing software to the
clearinghouse or directly to the insurance carrier. The claim file must be in a standard
electronic format as defined by the receiver.

Electronic Funds Transfer (EFT) - An electronic paperless means of transferring money.

This allows funds to be transferred, credited, or debited to a bank account and eliminates the
need for paper checks.

E/M - Evaluation and Management section of the CPT codes. These are the CPT codes 99201
thru 99499 most used by physicians to access (or evaluate) a patient's treatment needs.

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EMR - Electronic Medical Records. This is a medical record in digital format of a patient's
hospital or provider treatment.

Enrollee - Individual covered by health insurance.

EOB - Explanation of Benefits. One of the medical billing terms for the statement that comes
with the insurance company payment to the provider explaining payment details, covered
charges, write offs, and patient responsibilities and deductibles.
ERA - Electronic Remittance Advice. This is an electronic version of an insurance EOB
that provides details of insurance claim payments. These are formatted in according to the
HIPAA X12N 835 standard.

Fee For Service - Insurance where the provider is paid for each service or procedure
provided. Typically allows patient to choose provider and hospital. Some policies require the
patient to pay provider directly for services and submit a claim to the carrier for
reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.

Fee Schedule - Cost associated with each treatment CPT medical billing codes.

Financial Responsibility - The portion of the charges that are the responsibility of the patient
or insured.

Fiscal Intermediary (FI) - A Medicare representative who processes Medicare claims.

Formulary - A list of prescription drug costs which an insurance company will provide
reimbursement for.

Fraud - When a provider receives payment or a patient obtains services by deliberate,

dishonest, or misleading means.

GPH - Group Health Plan. A means for one or more employer who provide health benefits or
medical care for their employees (or former employees).

Group Name - Name of the group or insurance plan that insures the patient.

Group Number - Number assigned by insurance company to identify the group under which
a patient is insured.

Guarantor - A responsible party and/or insured party who is not a patient.

HCFA - Health Care Financing Administration. Now known as CMS (see above in Medical
Billing Terms).

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HCPCS - Health Care Financing Administration Common Procedure Coding System.

(pronounced "hick-picks"). Three level system of codes. CPT is Level I. A standardized
medical coding system used to describe specific items or services provided when delivering
health services. May also be referred to as a procedure code in the medical billing glossary.
The three HCPCS levels are:

● Level I - American Medical Association's Current Procedural Terminology (CPT)

codes.
● Level II - The alphanumeric codes which include mostly non-physician items or
services such as medical 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 private insurers for specific areas or programs.

Healthcare Insurance - Insurance coverage to cover the cost of medical care necessary as a
result of illness or injury. May be an individual policy or family policy which covers the
beneficiary's family members. May include coverage for disability or accidental death or
dismemberment.

Healthcare Provider - Typically a physician, hospital, nursing facility, or laboratory that

provides medical care services. Not to be confused with insurance providers or the
organization that provides insurance coverage.

Health Care Reform Act - Health care legislation championed by President Obama in 2010
to provide improved individual health care insurance or national health care insurance for
Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.

HIC - Health Insurance Claim. This is a number assigned by the the Social Security
Administration to a person to identify them as a Medicare beneficiary. This unique number
is used when processing Medicare claims.

HIPAA - Health Insurance Portability and Accountability Act. Several federal regulations
intended to improve the efficiency and effectiveness of health care. HIPAA has introduced a
lot of new medical billing terms into our vocabulary lately.

HMO - Health Maintenance Organization. A type of health care plan that places restrictions
on treatments.

Hospice - Inpatient, outpatient, or home health care for terminally ill patients.

ICD-9 Code - Also known as ICD-9-CM. International Classification of Diseases

classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.

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ICD 10 Code - 10th revision of the International Classification of Diseases. Uses 3 to 7 digit.
Includes additional digits to allow more available codes. The U.S. Department of Health and
Human Services has set an implementation deadline of October, 2013 for ICD-10.

Incremental Nursing Charge - Charges for hospital nursing services in addition to basic
room and board.

Indemnity - Also referred to as fee-for-service. This is a type of commercial insurance

were the patient can use any provider or hospital.

In-Network (or Participating) Provider - An insurance plan in which a provider signs a

contract to participate in. The provider agrees to accept a discounted rate for procedures.

Inpatient - Hospital stay of more than one day (24 hours).

IPA - Independent Practice Association. An organization of physicians that are contracted

with a HMO plan.

Intensive Care - Hospital care unit providing care for patients who need more than the typical
general medical or surgical area of the hospital can provide. May be extremely ill or seriously
injured and require closer observation and/or frequent medical attention.

MAC - Medicare Administrative Contractor. Contractors who process Medicare claims.

Managed Care Plan - Insurance plan requiring patient to see doctors and hospitals that are
contracted with the managed care insurance company. Medical emergencies or urgent care are
exceptions when out of the managed care plan service area.

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 insurance typically
then pays 100% of eligible expenses.

Medical Assistant - A health care worker who performs administrative and clinical duties
in support of a licensed health care provider such as a physician, physician's assistant, nurse,
nurse practitioner, etc.

Medical Coder - Analyzes patient charts and assigns the appropriate code. These codes
are derived from ICD-9 codes (soon to be ICD-10) and corresponding CPT treatment
codes and any related CPT modifiers.

Medical Billing Specialist - Processes insurance claims for payment of services performed by a
physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance
information are entered correctly and submitted to insurance payer. The specialist enters insurance

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payment information and processes patient statements and payments. Performs tasks vital to the
financial operation of a practice. Knowledgeable in medical billing terminology.

Medical Necessity - Medical service or procedure that is performed on for treatment of an

illness or injury that is not considered investigational, cosmetic, or experimental.

Medical Record Number - A unique number assigned by the provider or health care facility
to identify the patient medical record.
MSP - Medicare Secondary Payer.

Medical Transcription - The conversion of voice recorded or hand written medical

information dictated by health care professionals (such as physicians) into text format
records. These records can be either electronic or paper.

Medicare Coinsurance Days - Medical billing terminology for inpatient hospital coverage
from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying
for part of the costs during those days. After the 90th day, the patient enters "Lifetime
Reserve Days."

Medigap - Medicare supplemental health insurance for Medicare beneficiaries which may
include payment of Medicare deductibles, coinsurance and balance bills, or other services not
covered by Medicare.

Modifier - Modifier to a CPT treatment code that provide additional information to insurance
payers for procedures or services that have been altered or "modified" in some way. Modifiers
are important to explain additional procedures and obtain reimbursement for them.

N/C - Non-Covered Charge. A procedure not covered by the patient's health insurance
plan.

NEC - Not Elsewhere Classifiable. Medical billing terminology used in ICD when
information needed to code the term in a more specific category is not available.

Network Provider - Health care provider who is contracted with an insurance provider to
provide care at a negotiated cost.

Nonparticipation - When a healthcare provider chooses not to accept Medicare-

approved payment amounts as payment in full.

NOS - Not Otherwise Specified. Used in ICD for unspecified diagnosis.

NPI Number - National Provider Identifier. A unique 10 digit identification number required
by HIPAA and assigned through the National Plan and Provider Enumeration System
(NPPES).

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Out-of Network (or Non-Participating) - A provider that does not have a contract with
the insurance carrier. Patients usually responsible for a greater portion of the charges or
may have to pay all the charges for using an out-of network provider.

Out-Of-Pocket Expense - The amount the patient is responsible to pay to the provider
under their insurance policy. Anything above this limit is the insurers obligation. These
Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as
prescriptions.

Outpatient - Typically treatment in a physician's office, clinic, or day surgery facility

lasting less than one day.

Palmetto GBA - An administrator of Medicare health insurance for the Centers for Medicare
& Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of
BlueCross BlueShield of South Carolina based in Columbia, South Carolina.

Patient Responsibility - The amount a patient is responsible for paying that is not covered
by the insurance plan.

PCP - Primary Care Physician - Usually the physician who provides initial care and
coordinates additional care if necessary.

POS - Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health
Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-
HMO network providers. When a non-HMO specialist is seen without referral from the
Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage
of the coinsurance.

POS (Used on Claims) - Place of Service. Medical billing terminology used on medical
insurance claims - such as the CMS 1500 block 24B. A two digit code which defines where
the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is
for inpatient hospital, etc.

PPO - Preferred Provider Organization. Commercial insurance plan where the patient can
use any doctor or hospital within the network. Similar to an HMO.

Practice Management Software - software used for the daily operations of a provider's
office. Typically used for appointment scheduling and billing.

Preauthorization - Requirement of insurance plan for primary care doctor to notify the
patient insurance carrier of certain medical procedures (such as outpatient surgery) for
those procedures to be considered a covered expense.

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Pre-Certification - Sometimes required by the patients insurance company to determine
medical necessity for the services proposed or rendered. This doesn't guarantee the benefits
will be paid.

Predetermination - Maximum payment insurance will pay towards surgery,

consultation, or other medical care - determined before treatment.

Pre-existing Condition (PEC) - A medical condition that has been diagnosed or treated
within a certain specified period of time just before the patients effective date of coverage. A
Pre-existing condition may not be covered for a determined amount of time as defined in the
insurance terms of coverage (typically 6 to 12 months).

Pre-existing Condition Exclusion - When insurance coverage is denied for the insured when
a pre-existing medical condition existed when the health plan coverage became effective.

Premium - The amount the insured or their employer pays (usually monthly) to the health
insurance company for coverage.

Primary Subscriber (Insured) - The person under whom the insurance policy is obtained.

Privacy Rule - The HIPAA privacy standard establishes requirements for disclosing what the
HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a
patient about the status of their health, treatment, or payments.

Provider - Physician or medical care facility (hospital) who provides health care services.

PTAN - Provider Transaction Access Number. Also known as the legacy Medicare
number.

Referral - When one provider (usually a family doctor) refers a patient to another provider
(typically a specialist).

Remittance Advice (R/A) - A document supplied by the insurance payor with information
on claims submitted for payment. Contains explanations for rejected or denied claims. Also
referred to as an EOB (Explanation of Benefits).

Responsible Party - The person responsible for paying a patient's medical bill. Also referred
to as the guarantor.

Scrubbing - Process of checking an insurance claim for errors in the health insurance
claim software prior to submitting to the payer.

Self-Referral - When a patient sees a specialist without a primary physician referral.

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Self Pay - Payment made at the time of service by the patient.

Secondary Insurance Claim - claim for insurance coverage paid after the primary
insurance makes payment. Secondary insurance is typically used to cover gaps in
insurance coverage.

Security Standard - Provides guidance for developing and implementing policies and
procedures to guard and mitigate compromises to security. The HIPAA security standard is
kind of a sub-set or complement to the HIPAA privacy standard. Where the HIPAA policy
privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy
security laws apply more specifically to electronic PHI.

Skilled Nursing Facility - A nursing home or facility for convalescence. Provides a high level
of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an
alternative to an extended hospital stay or home nursing care.

Specialist - Physician who specializes in a specific area of medicine, such as urology,

cardiology, orthopedics, oncology, etc. Some health care plans require beneficiaries to obtain
a referral from their primary care doctor before making an appointment to see a Specialist.

Subscriber - Medical billing term to describe the employee for group policies. For
individual policies the subscriber describes the policyholder.

Superbill - One of the medical billing terms for the form the provider uses to document the
treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9
diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance - Additional insurance policy that covers claims for deductibles
and coinsurance. Frequently used to cover these expenses not covered by Medicare.

TAR - Treatment Authorization Request. An authorization number given by insurance

companies prior to treatment in order to receive payment for services rendered.

Taxonomy Code - Specialty standard codes used to indicate a provider's specialty

sometimes required to process a claim.

Term Date - Date the insurance contract expired or the date a subscriber or dependent
ceases to be eligible.

Tertiary Insurance Claim - Claim for insurance coverage paid in addition to primary and
secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary
insurance may not cover.

Third Party Administrator (TPA) - An independent corporate entity or person (third

party) who administers group benefits, claims and administration for a self-insured

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company or group.

TIN - Tax Identification Number. Also known as Employer Identification Number (EIN).

TOS - Type of Service. Description of the category of service performed.

TRICARE - This is federal health insurance for active duty military, National Guard and
Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

UB04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to
CMS 1500. Replaces the UB92 form.

Unbundling - Submitting several CPT treatment codes when only one code is necessary.

Untimely Submission - Medical claim submitted after the time frame allowed by the
insurance payer. Claims submitted after this date are denied.

Upcoding - An illegal practice of assigning an ICD-9 diagnosis code that does not agree
with the patient records for the purpose of increasing the reimbursement from the insurance
payor.

UPIN - Unique Physician Identification Number. 6 digit physician identification number

created by CMS. Discontinued in 2007 and replaced by NPI number.

Utilization Limit - The limits that Medicare sets on how many times certain services can be
provided within a year. The patient's claim can be denied if the services exceed this limit.

Utilization Review (UR) - Review or audit conducted to reduce unnecessary inpatient or

outpatient medical services or procedures.

V-Codes - ICD-9-CM coding classification to identify health care for reasons other than
injury or illness.

Workers Comp - Insurance claim that results from a work related injury or illness.

Write-off - Typically reference to the difference between what the physician charges and what
the insurance plan contractually allows and the patient is not responsible for. May also be
referred to as "not covered" in some glossary of billing terms

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Flow Chart of Medical Billing Process

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