Catalog

What is medical billing ...............................................................................................................................................................................1

1. What is RCM.......................................................................................................................................................................................2
2. CMS-1500............................................................................................................................................................................................2
3. what is RARC and CARC.................................................................................................................................................................2
1) CALL........................................................................................................................................................................................................2
2) WEBSITE................................................................................................................................................................................................3
3) VISITING TO DOCTOR FRONT OFFICE........................................................................................................................................3
1. HMO.....................................................................................................................................................................................................12
2. PPO......................................................................................................................................................................................................12
3. POS......................................................................................................................................................................................................12
4. EPO......................................................................................................................................................................................................13
5. HDHP...................................................................................................................................................................................................13
1. Medicare............................................................................................................................................................................................13
2. Medicaid.............................................................................................................................................................................................13
3. TRICARE.............................................................................................................................................................................................13
4. CHIP.....................................................................................................................................................................................................13

AR Caller, or Accounts Receivable Caller, follows up with insurance companies and

patients to resolve unpaid or denied medical claims. The role includes reviewing
EOBs/ERAs, identifying the reason for non-payment, contacting payers for claim status,
resolving denials, resubmitting or appealing claims, updating the billing system with call
notes,

What is medical billing

Catalog
2. What is RCM 2
3. CMS-1500 2
1) CALL 3
2) WEBSITE 3
3) VISITING TO DOCTOR FRONT OFFICE 3
1. HMO 12
2. PPO 12
3. POS 12
4. EPO 13
5. HDHP 13
1. Medicare 13
2. Medicaid 13
3. TRICARE 13
4. CHIP 13

Medical billing is the process of preparing, submitting, and following up on healthcare claims to
insurance companies to receive payment for services provided by doctors, hospitals, or other
healthcare providers.

11.What Is Medical Coding

Medical coding is essential for translating healthcare diagnoses, procedures, and services into
standardized codes, facilitating accurate billing, data management, and improved patient care.
1. What is RCM

Revenue Cycle Management (RCM) refers to the end-to-end process healthcare

providers use to manage patient revenue—from appointment scheduling and registration
to final payment collection.

The goal of RCM is to collect the full revenue for services rendered, as quickly and
efficiently as possible.

2. 1iCMS-1500

The CMS-1500 form is a standardized medical claim form used by non-institutional healthcare
providers to bill insurance companies, including Medicare and Medicaid. This form allows
physicians, nurses, clinical staff, ambulance services, and other individual providers to request
reimbursement for medical services rendered to patients

3. what is RARC and CARC

CARC (Claim Adjustment Reason Code) provides the primary reason for a claim adjustment,
while RARC (Remittance Advice Remark Code) offers additional details or context regarding that
adjustment.

What is Denial Management

Denial management is the systematic process of identifying, analyzing, and resolving claim denials in
healthcare organizations. It involves activities such as:

Identifying denials
Analyzing root causes
Resolving denials
Submitting appeals
Implementing process improvements
Taking corrective actions

1) RCM

1. APPOINTMENT SCHEDULING & PRE- REGISTRATION :-

IT IS A DEPARTMENT WHERE PATIENT WILL FIX AN APPOINTMENT WITH DOCTOR VIA 3 WAYS
1) CALL

2) WEBSITE
1
 3) VISITING TO DOCTOR FRONT OFFICE

Collect patient details,Determine visit type,Check provider availabilityConfirm insurance

participation,Provide patient instructions

2. ELIGIBILITY & BENEFIT VERIFICATION :-

i) ELIGIBIITY IS A DEPARTMENT WHERE PATIENT ACTIVE INSURANCE WILL BE VERIFIED.

ii) BENEFIT IS A DEPARTMENT WHERE PATIENT CO-PAYMENT , CO-INSURANCE,

DEDUCTIBLE, IN NETWORK PROVIDER , OUT NETWORK PROVIDER AUTHORISATION

WILL BE VERIFIED.

In-Network Providers are healthcare providers (doctors, hospitals, labs, etc.) who

have a contract with the patient’s insurance company to provide services at

negotiated, discounted rates.

Out-of-Network Providers are healthcare providers who do not have contract with

the patient’s insurance company.Because there’s no negotiated rate, services

from these providers usually cost much more for the patient — and in some plans,

they may not be covered at all.

Gather Patient & Insurance Information,Check Eligibility,Real-time eligibility tools

in the Practice Management (PM) system,Payer portals,Clearinghouse

portals,Phone verification,Verify Benefits,Check Authorization & Referral

Requirements,Document Verification

3.REGISTRATION :-

REGISTRATION IS A DEPARTMENT WHERE PATIENT ACCOUNT NUMBER WILL BE

GENERATE IN DOCTOR SOFTWARE . IN REGISTRATION PATIENT HAS TO SIGN 5 FORMS

Collect Demographic Information,Capture Insurance Details,Verify Eligibility &

Benefits,Collect Financial Information,Obtain Consent & Privacy Forms,Enter Information

into the PM/EHR System

AOB,ROI,ABN,LW,COB
 1.ASSIGNMENT OF BENEFIT (AOB) BOX NO- 13

IT IS A DOCUMENT SIGN BY PATIENT GIVING PERMISSION TO INSURANCE

COMPANY TO CREDIT TREATMENT AMOUNT GIVEN BY DOCTOR INTO DOCTOR A/C

NOT IN PATIENT A/C.

2.RELEASE OF INFORMATION ( ROI) BOX NO - 12

IT IS A DOCUMENT SIGN BY PATIENT GIVING PERMISSION TO INSURANCE COMPANY &

DOCTO TO RELEASE THE PATIENT MEDICAL INFORMATI

7.DEMO ENTRY & CHARGE CAPTURE :-

i) DEMO ENTRY IS A DEPARTMENT WHERE PATIENT DEMOGRAPHIC DETAILS

ENTER INTO CLAIM FORM. (1 TO 13 )

Patient Details,Insurance Information,Guarantor Details,Provider Details

ii) CHARGE CAPTURE IS A DEPARTMENT WHERE TREATMENT EXPENSES &

CHARGES WILL BE ENTER INTO CLAIM FORM (14 TO 33)

Sources of Charge Capture,Data Captured

8.CLAIM GENERATION & SUBMISSION :-

IT IS A DEPARTMENT WHERE CLAIM WILL BE PROPERLY GENERATION INTO CLAIM

FORM & SUBMISSION TO INSURANCE COMPANY

Note: how to send claim to insurance cmpy through clearing house

In medical billing and RCM, Claim Generation & Submission is the stage where all the

collected patient, provider, service, and coding data is assembled into an insurance

claim and sent to the payer for reimbursement.

VIA 2 WAYS

i) MAIL

ii) ELECTRONIC WAY

9.CLEARING HOUSE :-

IT IS A THIRD PARTY APPLICATION IT’S ACT AS middleman between the

healthcare provider and the insurance company. HELP AS KNOW WHETHER CLAIM

ACCEPTED OR REJECTED FROM INSURANCE COMPANY.

If rejected the claim they will send to the provider with scabbier report

Receive Claims,Claim Scrubbing,Payer Routing,Acknowledgment Reports

 Send back reports (EDI 277 or 999/277CA files) confirming claim acceptance

or listing rejections.

10.INSURANCE OFFICE :-

IT IS A DEPARTMENT WHERE THEY WILL ADJUDICATE WHETHER CLAIM NEED BE

PAID OR DENIED .THEY WILL RESPONSE INTO 2 WAYS.

i) EOB ( EXPLANATION OF BENEFIT ) PAPER STATEMENT

ii) ERA (ELECTRONIC REMITANCE ADVICE ) ELECTRONIC STATEMENT

11. PAYMENT POSTING :-

IT IS A DEPARTMENT WHERE PAYMENT WILL BE POSTED INTO DOCTOR

SOFTWARE REFFERING EOB & ERA .

Types of Payment Posting

Manual Posting -

staff enters payment details manually into the PM system.

Used when payment info is on paper EOBs or for small volumes.

Auto-Posting

Payments are uploaded directly from ERA files into the billing system.

Speeds up processing and reduces manual errors.

12.ACCOUNT RECEIVABLE (AR)

IT IS A DEPARTMENT WHERE THEY WILL WORK ONLY FOR INSURANCE

OUSTANDING BALANCE & TOWARDS RESOLUTION .

AR AS 4 SCENARIOS

I) DENIED CLAIM ( DENIAL MANAGEMENT )

ii) PARTIALLY PAID CLAIM

iii) OVER PAID CLAIM

 iv) NO RESPONSE CLAIM

Purpose of A/R in RCM

Track unpaid claims and patient balances.

Identify delays in payment.

Ensure timely follow-up to improve cash flow.

Reduce the Days in A/R (average time to collect money).

Types of A/R

Insurance A/R

Amounts owed by primary, secondary, tertiary insurance.

Includes pending, denied, or underpaid claims.

Patient A/R

Balances owed directly by the patient (copay, deductible, coinsurance, self-pay).

A/R Aging

Aging reports group unpaid balances based on how long they’ve been outstanding:

0–30 days – recently submitted claims (normal).

31–60 days – slightly delayed; follow-up may start.

61–90 days – at risk; urgent follow-up needed.

91–120 days – high risk of nonpayment.

120+ days – very high risk; may require collections.

13.COLLECTION :-

IT IS A DEPARTMENT WHERE THEY WILL WORK ONLY FOR PATIENT OUSTANDING

BALANCE.

In medical billing and RCM, Collections refers to the process of recovering

unpaid balances from both insurance companies and patients after services
have been provided
The differences between medical coding and medical billing are as follows:

Medical Coding: Medical coding is essential for translating healthcare

diagnoses, procedures, and services into standardized codes, facilitating
accurate billing, data management, and improved patient care.

Medical Billing: Involves submitting claims and receiving payments for

medical services provided. It deals with the financial aspects of
healthcare, ensuring that healthcare providers are compensated for their
services.

Responsibilities of a Medical Biller

 Submitting claims to insurance companies.

 Verifying patient insurance details.
 Resolving billing disputes and ensuring timely payment.
 Handling patient billing inquiries and payment plans.
 Creating and submitting insurance claims
 Verifying patient insurance coverage
 Following up on denied or rejected claims
 Posting payments and reconciling balances
 Handling patient billing inquiries and disputes

Responsibilities of a Medical Coder

 Assigning appropriate codes to medical diagnoses and procedures.

 Reviewing physician notes and patient records.
 Ensuring compliance with healthcare regulations.
 Collaborating with medical billers for accurate claim processing
 Reviewing medical records for accuracy and completeness
 Assigning appropriate ICD-10, CPT, and HCPCS codes
 Ensuring compliance with federal regulations and insurance
requirements

 Working with healthcare providers to clarify documentation
Updating coding guidelines as per new industry standards

The types of medical codes

ICD-11: The latest version of the International Classification of Diseases,

used for diagnosis coding.

ICD-10-CM: The Clinical Modification of ICD-10, used for diagnosis coding

in the United States.
 ICD-10-PCS: The Procedure Coding System for inpatient hospital
procedures.

CPT: Current Procedural Terminology, used for reporting medical, surgical,

and diagnostic services.

HCPCS Level II: Healthcare Common Procedure Coding System, used for
billing non-physician services and supplies.

Medical Coding Sytems:

ICD-10: Diagnosis and Procedures
ICD-11: The ICD-10 Update
CPT: Medical Procedures and Services
HCPCS II: Non-Physician Services

What is CMS_1500 and UB-04

The CMS-1500 form is used by individual healthcare providers for

outpatient services, while the UB-04 form is used by institutional providers
for inpatient services.

Overview of Each Form

CMS-1500: This form is primarily used by individual healthcare providers,

such as physicians, therapists, to submit claims for services provided to
patients. It includes standardized information about the patient,. The CMS-
1500 form consists of 33 fields that need to be filled out for claim
purposes.

the UB-04 is used by institutional healthcare providers, such as hospitals,

nursing homes, and rehabilitation centers, to submit claims for services
provided to patients. including room and board charges and medical
equipment. The UB-04 form consists of 81 fields or form locators, allowing
for more detailed billing information.


Key Differences

CMS-1500: Used by individual providers (e.g., doctors, therapists) for

outpatient services.

UB-04: Used by institutional providers (e.g., hospitals, nursing facilities) for

inpatient services.

Purpose:
CMS-1500: Submits claims for professional services and procedures
performed by individual providers.

UB-04: Submits claims for facility services, including room and board, and
other institutional charges.

Fields and Information:

CMS-1500: Contains 33 fields, focusing on patient and provider

information, services provided, and charges.

UB-04: Contains 81 fields, allowing for detailed information about various

services, including multiple procedures and facility charges.

Billing Context:
CMS-1500: Typically used for billing under Medicare Part B and for
outpatient services.

UB-04: Typically used for billing under Medicare Part A and for inpatient
services.

Types of forms we have

The most common types include the CMS 1500 form, the UB-04 form, and
the ADA Dental form. CMS 1500 or HCFA-1500 form, this is the standard
form used by healthcare professionals and suppliers to bill Medicare
carriers and durable medical equipment regional carriers.

Commercial / Private Insurance Plans types

1. HMO
2. PPO
3. POS
4. EPO
5. HDHP

Government Insurance Plans/febberal

1. Medicare
2. Medicaid
3. TRICARE
4. CHIP
3. Other Plan Categories

Workers’ Compensation → Covers injuries/illnesses from the

workplace.

Auto Insurance (PIP/No-Fault) → Covers medical costs from auto

accidents.

Self-Funded Employer Plans → Employer pays claims directly, but

uses an insurance company for administration.

*. Denial reason code (ANSI CARC/RARC)

Here are some commonly used mnemonics in RCM / medical billing:

1. SOAP – for Clinical Documentation

S – Subjective (patient’s complaint, symptoms)

O – Objective (exam findings, lab results)

A – Assessment (diagnosis)

P – Plan (treatment, follow-up)

(Helps ensure documentation supports coding and billing.)

2. COPE – for Denial Management

C – Correct the error

O – Organize documentation

P – Provide supporting evidence

E – Engage with payer for follow-up

3. DRG (in coding) – Diagnosis-Related Group

Not exactly a mnemonic, but often remembered as:

D – Diagnosis
R – Related

G – Group

(Helps inpatient billers group services for Medicare reimbursement.)

4. TACT – for Claims Submission

T – Timely submission (within payer’s deadline)

A – Accuracy in patient/provider info

C – Correct coding & modifiers

T – Tracking acknowledgments

5. SMART – for AR Follow-up Goals

S – Specific

M – Measurable

A – Achievable

R – Relevant

T – Time-bound

6. CREDO – for Insurance Eligibility Verification

C – Coverage check

R – Referral/authorization status

E – Effective date of coverage

D – Deductibles & copays

O – Out-of-pocket maximum remaining

Software Platforms in medical billing and coding

EPIC

MMDS

NextGen

Kareo

Kareo

AdvancedMD

Medical Management Data System (MMDS)

A software platform or set of tools used by healthcare providers, payers,

or billing companies to store, process, and analyze medical and billing
data for decision-making.

Functions of MMDS in Medical Billing

Data Storage & Integration

Holds patient demographics, insurance info, coding data, and payment

history.

Integrates with EHR, PM, and clearinghouse systems.

Claim Tracking

Monitors claims from submission to payment.

Flags rejections and denials.

Utilization Review

Tracks medical services usage to ensure they meet payer guidelines.

Analytics & Reporting

Denial trend analysis

Revenue forecasting

Provider productivity reports

Decision Support

Suggests corrective actions for rejected claims.

i