AR-General Billing

User Manual
This page intentionally left
blank
 Understanding U.S Healthcare & Billing Cycle

Introduction to U.S Healthcare

Healthcare in the United States - Provided by many distinct organizations.

• Health care facilities - largely owned and operated by private sector businesses.

• 62% of the hospitals - non-profit, 20% - government owned, 18% - for profit.

• 60–65% of healthcare provision and spending - Medicare, Medicaid, TRICARE, the Children's Health Insurance
Program, and Veterans Health Administration.

• Nearly 87% of the US population is covered by health insurance after adoption of the Patient Protection and
Affordable Care Act [PPACA]

Population under 67 years of age:

Mostly insured by their or a family member's employer,

Some buy health insurance on their own,

The remainder - uninsured.

Health insurance for public sector employees - primarily provided by the government.

Major Participants in U.S Healthcare

The US healthcare system revolves around

o Patients

o Providers

o Payers/Insurance Companies

Patient – One who gets / takes the medical treatment

Provider – One who renders / performs the medical treatment

Payer – One who pays for the medical treatment

3P Network / Participants in US Healthcare

1. Patient

A person who visits a doctor with ailment or health related issue to take the treatment from a physician.

Patient Types

I. New Patient - A patient who visits the hospital or provider’s office for the first time or after a break of three
years is called a new patient.
II. Established Patient - A patient who visits the hospital or provider’s office continuously or for the consecutive
visit where the break two visits does not exceed three years.

2. Healthcare Provider

A "health care provider" is an individual or institution licensed by the federal government to provide Healthcare
services.

3. Insurance / Payer / Payor / Carrier – Definition

Insurance is a contract between two parties the insurer and the insured, known as the policyholder, where the
insurer agrees to give coverage benefits that the policy holder could face in exchange for an equated instalment of
money known as premium.
US Healthcare VS Indian Healthcare System

Understanding Outsourcing

Outsourcing is contracting with another company or person to do a particular function. In other words, it is also
delegating work from one entity to another entity.

Outsourcing - Types

I. On Shore Outsourcing – Work outsourced within country

II. Off Shore Outsourcing – Work outsourced outside country

Revenue Cycle Management (RCM)

1. Scheduling: Fixing an appointment with the doctor. This can be done over the phone / internet / in person.

2. Registration: Patient fills his / her Demographic information (Personal, Insurance, Guarantor, & Employer info)
on a form called Registration form / Demographic Sheet / Face Sheet. Along with these two consent forms has
to be signed,
AOB – Assignment of Benefits (Need to be signed by Subscriber)
ROI – Release of Information (Need to be signed by Patient)

3. Insurance Verification: Front office / back office executive at provider’s office checks the patient’s coverage
information with their respective insurance companies.

4. Encounter: Provider gives medical treatment to patient and also records the treatment information in a device.
Later those voice files are sent to transcription team for medical transcription.

5. Medical Transcription: It’s a process where the voice files are converted to text files. The resultant document is
called Transcribed sheet.
6. EMR / EHR: Due to technological development, most of the providers now use voice recognition software which
enables them to generate Medical Records instantaneously. These are called EMR/EHR (Electronic Medical
Record or Electronic Health Record).

7. Medical Coding: Assigning pre-defined numeric and alpha numeric codes to the disease and treatment is known
as Medical Coding. The resultant document is called Charge Sheet.

8. Demo Entry: Process of entering demographic information into the provider’s billing software is called
Demographic Entry or Demo Entry. The main purpose of Demo Entry is to create an account for the patient in
the provider’s software.

9. Charge Entry: Once the Medical Record is coded, it becomes a charge sheet or charge ticket. The entry of
medical codes, DOS, provider information from the charge sheet or charge ticket better known as Charge
Description Master (CDM) into the Practice Management System (PMS) is called Charge Entry. Charge Entry is
the process where the claims are prepared.

10. Claim Transmission: Once claim created it will be sent to insurance companies from the Billing office. Electronic
claims need to go through Clearing House and Paper claims can be sent directly to Insurance.

11. Clearing House: Helps provider to submit the electronic claim to insurance company. Main function of clearing
house to convert the electronic claim into insurance specific format.
 12. Insurance : Once insurance company receives the claim, it will go through three steps,

I. Pre-Edit/Audit – Claims with missing / incorrect info will be rejected. Clean claims will be sent to next
step.
II. Adjudication – Decision will be made whether to pay or deny the claim
III. Communication of Decision – Decision made on the claim will be sent over to provider & patient
through a correspondence called as EOB.

13. Payment Posting: This department in the Billing office that is responsible for posting the payments received
from the Insurance and the Patients into the Practice Management System (PMS). This team is also responsible
for posting the denials received from the Insurance for further action.

14. Accounts Receivable: Team follows up with the insurance company, if there is a partial payment / denial / no
response on the claims that was submitted to insurance. Also follows up on the payments that are supposed to
be received from the patient.

15. Collections: This is a third party responsible for collecting the unpaid balances from the patient.

PROVIDERS

Healthcare Provider - A "health care provider" is an individual or institution licensed by the federal government to
provide Healthcare services. They are classified into 2 types INDIVIDUAL & FACILITY
Physician Individual providers are sub classified into PCP & SCP

1. Primary care physician (PCP)

• PCP is trained in general medical care

• Treats routine problems of the patient like fever, cold, cough etc.

• PCP manages the general care of the patient.

2. Specialty care physician (SCP)

• SCP has advanced medical training than PCP

• They are specialized in one part of the body or in certain field of medicine

• Example: Cardiologist, Neurologist, ENT, Dentists etc..

Facility providers are sub classified into:

1. Hospitals –
• Acute Care Hospitals –
I. Intensive care on short term basis
II. Could include an overnight stay
• Chronic Care Hospitals –
I. Long term care
II. Care is not as intensive in an acute care hospital

2. Ambulatory surgery center –

• Ambulatory surgery is a surgery that does not require an overnight stay.
• It is also called as day surgery/same-day surgery (SDS)
• The purpose of outpatient surgery is to keep hospital costs down, as well as saving the patient’s time
that would otherwise be wasted in hospital.
Example: Eye surgeries, cataract, laparoscopic surgeries, ears, nose, and throat procedures.

3. Skilled Nursing Facility-

• Primarily provides in-Patient treatment and less expensive
• Less intensive than acute care and is usually for a long-term basis
• Skilled nurses are available 24/7 and they provide treatment or medical monitoring and visiting doctor
available on a call.
• To get qualified for SNF, a patient must be hospitalized for 3 consecutive days.
• Type of service given at SNF by skilled nurses is usually for a long term.

4. Home Health-
• Preventative, supportive, rehabilitative, or therapeutic care is provided to a patient at home.
 • Physician certifies that patient is home bound and services have to be provided at home front. Usually
for the disabled, old & injured
• Provides medical, nursing, pathological or therapeutic treatment and assistance with essential activities
of daily living.

5. Hospice-
• For terminally ill persons (patients with a life expectancy of 6 months or less)
• Treatment for terminal illness stops during Hospice care
• Only symptom management and pain management is done.
• Examples: Cancer, HIV, ESRD (End stage renal disease).
• Services Provided in Hospice Care
I. Psychological, spiritual guidance and helping to cope with dying
II. Pain and symptom management
III. Education for family members on how to care for their loved ones.

6. Ambulance Services-
• They are offered by hospitals as well as by the individual entities (AMR)
• Ambulance is medically equipped mode of transport for a patient that carries them from a pick up point
to destination. Ex:- Residence to Hospital

7. DME manufacturers or suppliers –

• Equipment and supplies ordered by a health care provider for everyday or extended usage for patient at
home front.
• DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

8. Psychiatric care & Rehab care –

• Facility where mentally ill patients, drug addicts, alcoholics and chain smokers are treated

6. Renal Dialysis Centres –

• Regular check-ups & dialysis is conducted for patients suffering with kidney disorders, ESRD

7. Pharmacy –
• Prescription drugs and over the counter drugs are sold at these centres.
 Payers

Types of Payers

Federal/Government Commercial/Non Govt

Liability
• Medicare • Indemnity
• Workers
• Medicaid • BCBS Compensation
• Auto Liability
• Tricare • Managed Care
Organisations ( MCO)
• CHAMPVA

Federal/Government

1. MEDICARE
• Nation’s largest insurance program
• CMS administers Medicare
• CMS was earlier known as HCFA – Health Care Financing Administration
• Policies and guidelines are standard across US
• Timely Filing Limit is 1 year from DOS

Medicare Eligibility

• Persons of age 65 years and above

• Physically Challenged / disabled people
• People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney
transplant).

Medicare Beneficiary Identifier

• Medicare IDs are called as MBI (Medicare Beneficiary Identifier).

• The MBI has 11 characters which contain letters and numbers.
• Example :1EG4-TE5-MK73
• The MBI’s 2nd, 5th, 8th, and 9th characters will always be a letter.
• Characters 1, 4, 7, 10, and 11 will always be a number
• The 3rd and 6th characters will be a letter or a number.
• The dashes aren’t used as part of the MBI
COMPONENTS OF MEDICARE

1. Part A (Hospital Insurance)

• Receives Part A automatically, need not purchase.
• Covers in-patient hospital expenses
• Part A pays for:
o Care in hospitals as an inpatient Critical access hospitals
o Skilled Nursing Facilities
o Hospice Care
o Some Home health care.

2. Part B (Medical Insurance)

• Part B must be purchased
• Covers the outpatient health care & other services like ambulance, therapy, and few DME services.
• To purchase part B one should have part A coverage
• Part B helps pay for :
o Ambulance services
o Artificial limbs & eyes
o Arm, leg, back & neck braces
o Emergency care
o Preventive services
o Telemedicine in some rural areas etc.

3. Part C (Medicare Advantage Plan)

• Medicare Advantage (MA) is a United States health insurance program of Managed health care
(PPO) or (HMO) that serves as a substitute for "Original Medicare" Part A and B Medicare benefits.
• The private insurance companies are paid a fixed amount each month to cover Medicare
beneficiaries
• These plans must follow the rules (policies and guidelines) set by Medicare
• There are presently 3 types of Medicare Advantage Plans
o HMO
o PPO
o POS

4. Part D (Prescription Drug Plan)

• Private insurance company offers to Original Medicare beneficiaries.
• One needs to have both Part A & B to purchase Part D
• Covers pharmacy services and few non covered services of part A & B.

Medicare as Secondary Payer (MSP)

• Medicare Secondary Payer is the term used when it is not responsible for paying first.
• Medicare acts as secondary payer for the following-
o EGHP plans- small or large
o Black lung program
o Workers compensation plans
o Auto liability plans Ex: no-fault insurance
 o Beneficiaries with ESRD during the first 30 months
o Working Aged
o Disabled patients under 65 covered by a LGHP
o Veteran’s Administration

Railroad Medicare

• Railroad Medicare: It’s a Medicare program offered to retired Railway employees who are above 65

MEDIGAP

• Medigap policy is also known as “Medicare Supplemental Insurance”

• It is offered by private insurance companies to fill in the “gaps” in the coverage of the Original Medicare
Plan

• It helps pays for Medicare deductibles, coinsurances & co-payments & also covers some benefits that
Medicare doesn’t cover.

• The Medigap policy only works with the Original Medicare Plan

• The Medigap policy will not pay for deductibles, co pay or coinsurance if the beneficiary joins a Medicare
Advantage Plan

• The beneficiary must have both Part A & Part B to obtain Medigap coverage

• The Medigap policy will cover only one person

2. MEDICAID
• CMS and DHHS administers Medicaid
• Its jointly funded by state and federal government
• It is state-federal insurance
• Policies and guidelines are state specific
• Policy id format and timely filing limit is state specific.

Eligibility Criteria:
o Low income people (below poverty line – BPL)
o Families & Children
o Pregnant Women
o Elderly people & people with disabilities
o Low income adults in some states

• The policy is renewed on a monthly basis and the person has to update his monthly income to Medicaid
to re-new his policy
• No premium and no patient’s responsibility for beneficiaries
• However in few instances co-pay or spend down charges are applicable
• Medicaid is the payer of last resort
 • Spend down charges: Some people have too much income to qualify for Medicaid. This amount is called
excess income. Some of these people may qualify for Medicaid if they spend excess income on medical
bills. This is called a spend down.
• Example: A person over 65 is denied Medicaid because her monthly income is $50 more than the limit
for Medicaid eligibility. If she incurs medical bills of $50 per month, the rest of her medical bills will be
covered by Medicaid. The spend down in this case is the $50 of medical bills she incurs.

3. TRICARE
• Federal insurance offered for defense people and their family members
• Eligible beneficiaries have to enrolled in DEERS – Defense Enrolment Eligibility Reporting System
• Tricare was earlier referred as CHAMPUS- Civilian Health and Medical Program of the Uniform services.
Eligibility :
o Active Duty Service Members
o Eligible family members of active duty service members
o Military retirees & their eligible family members
o Surviving eligible family members of deceased, active or retired service members
o Wards & legally adopted children
Tricare plans :
o Tricare Prime – Active , Working
o Standard
o Extra - Retired people
o For Life - Life partners

4. CHAMPVA
• Civilian Health And Medical Program of the Veteran Administration/Affairs (CHAMPVA)
• Federal insurance for the veterans who are affected by it (injured or dead) and also for their family members
• Veterans - A person who has participated in a war

COMMERCIAL PAYER

1. MANAGED CARE ORGANIZATIONS/Managed Care Plan

• Managed care plans are mainly introduced to give better health benefit plan at affordable price and also to
avoid patient’s misuse of the policy.
• Network and PCP concept applicable
• Co-pay was introduced in managed care plan
• Preventative services are covered
• Authorization concept has been introduced
• Premium is less compared to Indemnity/Traditional plan.

1. Health Maintenance Organizations (HMO) plans

o A patient must first visit a primary care physician (PCP)
o Patient need to choose a PCP while purchasing the policy.
o PCP will refer the patient to specialist within the network if necessary.
o Referral number is given to patient by PCP to meet specialist.
o Covers only in-network providers.
o Out of network not covered.
 2. Preferred provider Organization (PPO) plans
o There is no role of a PCP
o Covers both in-network / out of network
o It’s a group plan type.
o Patients’ responsibility on a bill would be higher if he goes out of network
3. Point of Service Organization (POS) plans
o Role of a PCP when using in-network providers.
o No role of PCP when using out of network providers.
o It’s an individual plan type.
o Patients’ responsibility on a bill would be higher if he goes out of network

4. Indemnity Plan (Traditional or Commercial)

In this plan the insurance company usually pays 80 percent of the allowed amount and for the remaining
20 percent patient is responsible

Blue Cross Blue Shield

• It is the largest private health insurance in US.

• The Blue Cross and Blue Shield Association provides healthcare coverage for nearly 100 million people or
one-in-three Americans
• Healthcare coverage available in all 50 states, the District of Columbia and in Puerto Rico
• Nationwide, more than 90 percent of hospitals and 80 percent of physicians contract with BCBS
• Earlier Blue Cross used to process Hospital claims and Blue Shield used to process Physician claims.

BCBS has 2 groups:-

1. Federal BCBS –
o Federal BCBS offers insurance as EGHP to federal employees where federal government is the
employer.
o Policy id format is R followed by 8 digits, R12345678
2. Commercial BCBS –
o Commercial BCBS offers EGHP to private firms, indemnity plans, student plan, Managed care plan
etc.
o Policy id format ranges from 6-17 digits however generally it is XYZ123456789
o The first 3 letter alpha-prefix is the state code assigned for the policy id of a particular state
o Example: - NGL-BCBSOH, OPN-BCBSMI etc.

Home Plan

• It usually refers to the plan that is taken by the patient in his/her state where the patient resides & pays
premium.

Local Plan

• It usually refers to the plan/ state in which the patient takes treatment besides his/her Home plan.
 Blue Card

• Blue Card is a national program that enables members of one Blue Cross and Blue Shield (BCBS) Plan to
obtain health care services while traveling or living in another BCBS Plan's service area.
• The program links participating providers with the independent BCBS Plans across the country, through
a single electronic network for claims processing and reimbursement.
• When traveling inside the US – Blue Card

• When traveling outside the US – Blue Card Worldwide

• When working/ living outside the US – Blue Worldwide Expat

LIABILITY INSURANCE

1. Auto Liability
• Bodily injury to you and others
• Damage to someone else’s car or property
• Collision damage (covers damage to your car)
• The costs to defend yourself against bodily injury and property damage allegations
• The cost to repair your vehicles that are damaged in an accident
• The cost to rent a replacement vehicle while your damaged vehicle is being repaired
I. No Fault State Policy
o The drivers involved would submit a claim to their own auto insurance companies and receive
compensation from them.
o No-fault insurance is offered in No-Fault States
o Each state - own coverage stipulations and regulations.
o The system is simplified
o Immediate compensation is guaranteed
II. Non - No Fault State Policy
o Both the parties (involved in the accident) file a case in the court to determine the “fault”.
o Once the case is settled & the fault is proved, the auto insurance of the party at fault pays for both
the parties.
o There is no immediate compensation received
• 12 states fall under no fault and the remaining 38 states are non-no fault.

2. Workmen Compensation
• This plan covers only work-related problems.
• No premiums for employees.
• No patient responsibility.
• Regulated by the government but varies by state.
• The policy - in the name of the employer.
• Policy # - for employer & this is common for all the employees.
• Each injury reported by an employer - claim # .
• Claim # is unique to each person for each injury.
• Claim is handled via claim numbers & not by policy numbers.
• Claims to be submitted along with medical records.
• Role of an “adjustor”.
 Payment Methodology, EOB and Coding
Payment Methodology

Payment Basics.

1. Non-Participating Provider

Usual Customary & Reasonable – UCR

Provider paid according to the provider’s usual fee, the customary fee of other providers in the area, and the
reasonable fee for the service.

2. Participating Provider

Capitation

Fixed payments paid to a provider periodically for each patient assigned to the provider.

The provider is paid regardless of whether the patient is ever seen.

The most common arrangement is for a provider to be paid per member per month (PMPM)

Fee schedule

A listing of the maximum fee that an insurer or health plan will pay for a service based on the CPT code.

Case rate

Fixed provider payments per episode of care regardless of intensity of services or length of services.

Bundled

This is a type of payment where both technical charges and professional charges provided and billed by the same
provider are bundled together and paid.

Explanation of Benefit:

An EOB is a statement sent by an insurance company to both provider and patient to let them know their claim paid
or denied.

If an EOB sent electronically then it’s called as Electronic Remittance Advice.

EOB will be accompanied by Check or Electronic Fund Transfer (EFT) information, if a claim is paid.

1. Key Data Elements Of EOB

1) Insurance Information: Insurance name, Address, & Telephone #

2) Provider Information : Rendering Provider name, Tax Id / NPI, Billing Address of

The provider.

3) Patient Information : Patient name, Subscriber name, Policy id # , Policy Grp #

4) Claim Information : Date of Service (DOS), Claim #, Patient Acct #, Billed Amt,
Allowed Amt, Paid Amt, Patient’s Resp., Contractual Write-off, Procedure Codes,
Modifiers, and Remark Codes.

5) Check Information : Check #, Check Date, Check Amount.

6) Denial Information : Remark Codes / Explanation Codes for the Denial.

2. EOB Calculation
Allowed Amount = Total charge – Contractual adjustment

Patient Responsibility = Allowed Amount – Insurance Payment

Allowed Amount = Insurance Payment + Patient Responsibility

Total Charge = Contractual Adjustment + Allowed Amount

Codes & Modifiers:

What is Coding?

A Pre-defined alphanumeric codes are assigned to patient disease condition and treatment rendered to the patient.

Coding is a uniform language used in U.S Medical billing to communicate patient’s illness and treatment information
to the insurance companies.

It’s not possible to send all the patient’s medical records along with claim for each submission for processing and
also the people who process the claim are not doctors to understand medical terminologies. Hence we use coding
which is easier to understand.

1. Diagnosis Code

• It is used to describe the patient’s disease condition, illness or reason for the visit.
• Disease classification was done by WHO (World Health Organization)
• It is developed and updated by AHA (American Hospital Association) & CMS (Center For Medicare &
Medicaid Services)
• Manual which is used to bill diagnosis code is ICD-10-CM (International Classification of Disease, 10th
Revision Clinical Modification)
• Earlier edition was ICD-9-CM.

Evolution of ICD-10-CM

• ICD-10 code sets are implemented since October 1, 2015.

• ICD-10-CM is more specific and substantially different from ICD-9-CM.
• ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice.
• ICD-10 code structure talks about code category, etiology, anatomical site and severity which was not there
in ICD-9.
• ICD-10 has placeholder “XX” which can be used for future expansion.
• Ex: A12.0XX A

Combination of codes is there in ICD-10 CM.

2. Procedure Code
It is used to describe about the treatment given to the patient.
Procedure code classified into,

1) HCPCS Level I / CPT

2) HCPCS Level II

HCPCS (Healthcare Common Procedure Coding System)

CPT (Current Procedural Terminology)

HCPCS LEVEL I

• It is commonly known as CPT

• CPT is used to bill physician services or outpatient services / professional component.
• It is developed and updated by AMA. (American Medical Association).
• Format – 5 digits numeric

Ex: 78512, 23789

HCPCS LEVEL II

• It is used to bill technical component charges or DME charges which is not mentioned in CPT / Level I codes.
• It is developed and updated by CMS.
• Format: A-V followed by 4 numeric

Ex: A0427 , A0426

Modifiers

It is used when a procedure / treatment is altered or modified due to unavoidable circumstances.

Modifiers are used to indicate the following:

• A service or procedure has a technical component

• A service or procedure has a professional component
• A service or procedure was performed by more than one physician and / or one or more location
• A service or procedure has been increased or reduced
• Only part of a service or procedure was performed
• A bilateral service or procedure was performed
• A service or procedure was provided more than once and if any unusual events occurred etc.,
Types of Modifier:

CPT Modifiers

• Numeric in Character
• 2 digits
• Can be used with CPT codes

Ex: 50 – Bilateral Procedure, 26 – Professional Component

HCPCS Modifiers

• Alphabetic or Alphanumeric in character

• 2 Characters
• Can be used with both CPT Level I and Level II

Ex: TC – Technical component, LT – Left side

1. Modifier 1
A one character modifier represents a location type. Modifiers are used in combination with each other. The first
modifier is used to identify the origin; the second modifier is used to identify the destination. For example, “RH” is
used to represent a transport from a residence to a hospital. Unless otherwise required by the payer, the first
modifier field will contain this combination of the origin (From Location) and destination (To Location) modifiers.
2. Modifier 2

MOD2 Field: Government & Non-Government Modifiers (See local policy for Medicaid requirements)

3. Place of Service:
It represents the place where the patient was treated or seen.

Its 2 digit numeric code

Example:

POS Code Description

11 Office Visit

21 Inpatient - Hospital

22 Outpatient

23 Emergency Room

24 Ambulatory Surgery Center

31 Skilled Nursing Facility

34 Hospice

41 Ambulance [Land]

42 Ambulance [Water (or) Air]

 Terminologies
1. Patient – One who is injured or suffering from a disease or illness.

2. Provider – Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.

3. Insurance company – An organization contracted with patient to pay for his health care expenses. Also known
as Insurer/Payer/Carrier.

4. Premium – Amount paid periodically to purchase health insurance plan.

5. Enrollee / Guarantor / Subscriber / Member/ Policy holder / Insured / Beneficiary (term used by Medicare) - A
person who is covered by health insurance.

6. 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.

7. Centers for Medicare and Medicaid Services (CMS) – A government agency that oversees the Medicare and
Medicaid programs.

8. HCFA - Health Care Financing Administration. Former name of CMS.

9. HIPAA - Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the
privacy of your health information.

10. Account Number - Number given by doctor or hospital for a medical visit.

11. Pre-registration – In hospital where the patient admits his/her demographic details such as Name, DOB,
Address, Ph.# etc. (necessary for filing a claim) before consulting doctor.

12. Assignment of Benefits – A written consent, signed by the policy holder / patient (in absence of the policy
holder) to an insurance company, to pay benefits directly to the hospital.

13. Release of Information - A signed statement from patients or guarantors that allows doctors and hospitals to
release medical information so that insurance companies can pay claims.

14. Coordination of Benefits (COB) -A way to decide which insurance company is responsible for payment if the
patient has more than one insurance plan.

15. Primary Insurance Company - The insurance company who is responsible for paying the claim first. If patient has
another insurance company, it is referred to as the Secondary Insurance Company.

16. Secondary Insurance – the insurance plan that is billed after the primary has paid or denied payment.

17. Crossover claim - When claim information is automatically sent from Medicare to secondary insurance such as
Medicaid.
18. Medigap – It is also known as “Medicare Supplemental Insurance”, it is a health insurance policy sold by private
insurance companies to fill in the “gaps” in coverage under the original Medicare plan, like deductibles,
coinsurance & co-pay.

19. Outpatient (OP) – services performed at a facility where the patient stays less than 24 hours and is not admitted
to the facility.

20. Inpatient (IP) – A patient who has been admitted to a hospital and stays 24 hours or more.

21. Beneficiary Eligibility Verification - A way for doctors and hospitals to get information about the patient’s
insurance coverage / benefits.

22. Covered Charges/Expenses - Covered services are those medical procedures the insurer agrees to pay for. They
are listed in the policy.

23. Limited Policy - A policy that covers only specified accidents or sicknesses.

24. Non-Covered Charges – service or procedure not listed as a covered benefit in the payer’s master benefit list.
These may or may not be billable to the patient.

25. Exclusions - Specific conditions or circumstances for which the policy will not provide benefits.

26. Charity Care - Free or reduced-fee care provided due to financial situation of patients.

27. Ambulatory Surgery – Outpatient surgery or surgery that does not require an overnight hospital stay. Also
known as ‘Day surgery’ or ‘same day surgery’ (SDS).

28. Advanced Beneficiary Notice (ABN) - A notice the hospital or doctor gives the patient before the treatment,
telling patient that Medicare will not pay for some treatment or services. The notice is given to the patient so
that the patient may decide whether to have the treatment and how to pay for it.

29. Allowed amount / Considered amount – The dollar amount an insurance company deems fair for a specific
service or procedure.

30. Appeal – Steps used when the payer denies a service the patient thinks is needed or refuses to pay for care that
the patient has already received.

31. Appeal limit-The time frame that the insurance company gives to the provider to submit the claims & get
reimbursed after the claim has been denied. The appeal limit starts from date of denial. For Medicare it is 120
days & it varies with other insurance.

32. Authorization Number – To be obtained by the provider from Insurance company (UMR-Utilization
Management Review) before medical services are rendered to the patient. It relates not only whether a service
or the procedure is covered but also to find out whether it is medically necessary.
33. Mother baby clause - Mother Baby clause is rule in which a newborn baby is covered under the policy of the
mother for a period of 30 days from the date of birth.

34. Birthday rule - Birthday rule is a rule in determining the primary and secondary insurance for a child when the
parents are insured.

35. CDM (Charge Description Master) - inbuilt software where all billed amount for procedure codes are listed.

36. Claim – A medical bill / invoice sent to the insurance company.

37. CMS 1500 – This is the form that doctors use to submit a claim to the insurance company.

38. UB-04(Uniform billing-04)/ CMS 1450 - A form used by hospitals to file insurance claims for medical services.

39. Clearinghouse – an entity that forwards claims to insurance payers electronically.

40. 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.

41. Clean Claim - A claim is one which will pass through all front-end edits.

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

43. Out-of-Pocket Costs – the patient’s share of the cost of health care services. This includes co-payment, co-
insurance &/ or deductible.

44. Co-pay – A flat fee the patient pays each time for medical services. This is associated with managed care plans.

45. Coinsurance – A percentage of the cost that the patient is responsible to pay for the medical services received.
Co-insurance percentages vary depending on the health plan.

46. Deductible – Usually an annually fixed amount that the patient is responsible to pay for services; before any
payment is issued by the insurance company.

47. Explanation of Benefits / Remittance advice (EOB/RA) - The notice sent to the patient and the doctor from
patient's insurance company after processing claims explaining the status.

48. ERA - Electronic Remittance Advice; this is an electronic version of an insurance EOB that provides details of the
claim status.

49. Collection Agency - A business that collects money for unpaid bills.

50. Participating Provider (In-network provider) - A doctor or hospital who is contracted with the insurance
company, has agreed to certain terms and payment conditions set by the insurance plan.
51. Credentialing - The process used by health insurance companies to examine and verify the medical
qualifications of health care providers who want to participate in the network.

52. Fee schedule - A listing of the maximum fee that an insurer or health plan will pay for a service based on the CPT
code.

53. Capitation -Fixed payments paid to the contracted provider periodically for each patient assigned to the
provider. The provider is paid regardless of whether the patient is ever seen. The most common arrangement is
Per Member per Month (PMPM).

54. Contractual Adjustment (Discount) - The part of the bill that doctor or hospital must waive-off (not charge
patient) because of billing agreements with patient’s insurance company.

55. Non-Participating Provider (out of network provider) - A doctor, hospital or other healthcare provider who is
not part of an insurance plan’s doctor or hospital network.

56. UCR - Usual Customary & Reasonable Rate - The payment scale used in paying non- participating providers.
Providers are paid according to the provider's usual fee, the customary fee of other providers in the area, and
the reasonable fee for the service.

57. Date of Service – The date/s when the patient was treated.

58. Place of Service - This code indicates the location of service; whether the patient was treated at home, hospital,
office, clinic.

59. Diagnosis code – This code indicates the illness of the patient. The conclusion reached about a patient’s ailment
by thorough review of the patient’s history, examination, and review of laboratory data.

60. E Codes -codes used to describe external causes of injury, poisoning, or other adverse reactions affecting the
patient’s health.

61. V Codes – Codes assigned for preventive medicine services and for reasons other than disease or injuries.

62. HCPCS – a coding system used to report procedures, services, supplies, medicine, and durable medical
equipment. (Healthcare Common Procedure Coding System).

63. Procedure code – The code used to describe the services / treatment provided by the doctor / hospital.

64. CPT code– a five digit code used to report services and procedures by physicians. These are level I codes under
HCPCS.

65. National Code – four digits with a prefix (A-V) used to report services/supplies that include DME, injections &
drugs. These are level II codes under HCPCS.

66. Modifier - A modifier provides the means by which the reporting physician can indicate that a performed service
or procedure performed has been altered by some specific circumstances, but not changed by definition or code
assigned.
67. CPT modifier – a two-character numeric descriptor used only with CPT codes.

68. HCPCS modifier – a two-character alphabetic or alphanumeric descriptor used with both CPT level I and level II
National codes.

69. Emergency Care - Care given for a medical emergency when the patient's health is in serious danger; when
every second counts.

70. Durable Medical Equipment (DME) - Medical equipment that can be used many times, or special equipment
ordered by the doctor, usually for use at home.

71. Identify – To find or to recognize.

72. Policy Number / Member identification number / HIC number (Medicare) - A number that the insurance
company gives the policy holder to identify the insurance contract.

73. Federal Tax ID Number– A 9 digit number assigned by the federal government to doctors and hospitals for tax
purposes. (TIN format: 3-2-4 / 2-7)

74. W-9 Form -A tax form which certifies an individual's tax identification number.

75. Provider Identification Number (PIN) - Assigned by the Insurance company / health plan to their contracted
providers.(PIN format: Insurance specific).

76. National Provider Identifier (NPI) – Single block of 10-digits, intelligence-free, numeric identifier for providers
and suppliers issued by CMS. HIPAA mandates the usage of NPI. (It was earlier known as UPIN).

77. Taxonomy Code - Specialty standard codes used to indicate a providers specialty, this is sometimes required to
process a claim.

78. Fraud: To purposely bill for services that were never given or to bill for a service that has a higher
reimbursement than the service produced. Fraud includes offering and accepting kickbacks.

79. Abuse: The misuse of a person, substance, services such that harm is caused. Some of the healthcare abuses
include excessive or unwarranted use of technology, pharmaceuticals and services, abuse of authority, abuse of
privacy, confidentiality or duty to care.

80. Global Days - All surgical services have been assigned a "global time period," lasting up to a maximum of 90
days, for post-operative care. All follow-up care for the surgery performed within the assigned global period will
be considered part of the surgical reimbursement and not paid separately.

81. Group Insurance –An insurance that covers a group of people; usually availed through employment.
82. Insured Group Name - Name of the group insurance plan that insures the patient.

83. Insured Group Number - A number that your insurance company uses to identify a group insurance plan.

84. Internal Control Number (ICN) / Document Control Number (DCN) / Claim Number - A number that is assigned
to the claim form by the insurance company or their agent.

85. 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 days Increments.

86. Credit Balance - The balance amount that reflects in the client software or "Amount Due “column of the account
statement with a minus sign after the amount (for example: $50- ). It may also be shown as ($50). The provider
may owe the patient a refund / it could be a posting error.

87. In Process – A term used when the claim is received by the insurance company and is being reviewed.

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

89. Itemized statement / I-Bill – An itemized statement provides a complete listing or detailed account of every
service posted to a patient account. It includes the DOS, description of services, service code, charge amount,
estimated insurance amounts and totals.

90. Late charges - Charges discovered and processed after the initial final bill has been released.

91. Lock-box – Lock-box is a banking term used when a hospital has a ‘lock-box’ number at the bank for the checks
to come in.

92. Primary care physician (PCP) – A physician trained in general medicine who treats routine problems.

93. Specialty Care Physician (SCP) - A physician who specializes in treating certain parts of the body or specific
medical conditions. Ex: cardiologists only treat patients with heart problems.

94. Referral – Permission obtained from the primary care physician to seek services from a specialist for an
evaluation, testing, and treatment. Managed care plans require this.

95. Managed Care - Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and
many fee-for-service plans, have managed care.

96. HMO (Health Maintenance Organization) –A plan in which patients must use the doctors and hospitals
designated by the HMO.
97. PPO (Preferred Provider Organization) - A combination of traditional fee-for-service and an HMO. When you
use the doctors and hospitals that are part of the PPO, you can have a larger part of your medical bills covered.
You can visit other doctors, but at a higher cost.

98. Point-of-Service (POS) Plan - A plan offered by managed care. The primary care doctors usually make referrals
to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get
some coverage.

99. Medically Necessary - Many insurance policies will pay only for treatment that is deemed "medically necessary"
to restore a person's health. For instance, many health insurance policies will not cover routine physical exams
or plastic surgery for cosmetic purposes.

100. Medical Necessity - Medical information justifying that the service rendered or item provided is reasonable
and appropriate for the diagnosis or treatment of a medical condition or illness.

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

102. Medical Record Number - The number assigned by the doctor or hospital that identifies a patient’s medical
record.

103. Observation –Type of service used by doctors and hospitals to decide whether the patient needs inpatient
hospital care or can recover at home or in an outpatient area. It is usually charged by the hour.

104. Over-the-Counter Drug - Drugs that do not require a doctor’s prescription & could be bought at a pharmacy or
drug store.

105. Offset - When an insurance company makes a wrong or an excess payment to a provider, it would adjust the
amount in the subsequent claims. This is called an offset.

106. Pre-Existing Condition - A health condition or a medical problem that the insured has before signing up to
receive insurance coverage. Some health insurers may not pay for these health conditions; usually for a certain
period of time known as a waiting period.

107. Rebill – Means to resubmit a claim.

108. Super Bill –A form that lists procedures, services and diagnosis codes; this records the services performed for
the patient for a given visit.

109. Supplemental -Another name for secondary insurance. A supplemental plan; this usually picks up the patient’s
deductible and/or co-insurance.

110. Timely Filing Limit - The time frame that payers give to providers to submit the claims and get reimbursed.

111. Units of Service - Measures of medical services, such as the number of hospital days, pints of blood, kidney
dialysis treatments, etc.
112. Utilization Review (UR) - Hospital staff who work with doctors to ensure appropriate level of care for the
patient’s condition, arrange appointments with the primary and specialty physicians, obtain authorization #s,
advise the patient of discharges, assist with appeals process for denials received when applicable etc.

113. Write off -Write off is the amount that is waived off by the provider. This is usually a loss borne by the provider
due to various reasons.
SSN-Social Security Number

This is a unique 9 digit number given by the federal government through the social security office for the purpose of
identification, and to maintain a port folio of a person.

Format: XXX-XX-XXXX, 123-45-6789

The First 3 digits denote the Area (States in US)

The next 2 digits denote the Group (Odd# even#)

The last 4 digits denote the Serial (Chronological order)

American Names

All Americans have a ‘First name’ and a ‘Last name.’ The last name denotes their family name/surname. They also have
middle name but this is optional. The format in which an American name is documented is Last name, First name
Middle initial/name, if any.

Example: Brad Anthony Pitt is documented as Pitt, Brad A

Example: Tom Hanks is documented as Hanks, Tom

Note: Not to be read so while verbally communicating

Date format

The American calendar format is MM/DD/YYYY (Month/date/year)

Example: 15th August 2005 is 08/15/2005

Telephone #s and Fax #s

The American Telephone #s and Fax #s are 10 digits #s

Format: 212-823-9847, 800-258-6211

Note: The first three digits are called the Area code

Time Zones

America is a huge land mass and is therefore divided into 6 time zones

1. EST-Eastern Standard Time 2.CST-Central Standard Time

3. MST-Mountain Standard Time 4.PST-Pacific Standard Time

5. AST-Alaskan Standard Time 6.HST-Hawaiian Standard Time

Zip Codes

In India we have Pin Codes – In America we have Zip Codes. These are 5 digit #s that specifies a certain area.

Example: 75201 stand for Dallas, Texas* Some Zip codes can be 9 digits, for e.g. 75201-4521. The last 4 digits are not
compulsory.
 State Code Capital State Code Capital
Alabama AL Montgomery Montana MT Helena
Alaska AK Juneau Nebraska NE Lincoln
Arizona AZ Phoenix Nevada NV Carson City
Arkansas AR Little Rock New Hampshire NH Concord
California CA Sacramento New Jersey NJ Trenton
Colorado CO Denver New Mexico NM Santa Fe
Connecticut CT Hartford New York NY Albany
Delaware DE Dover North Carolina NC Raleigh
Florida FL Tallahassee North Dakota ND Bismarck
Georgia GA Atlanta Ohio OH Columbus
Hawaii HI Honolulu Oklahoma OK Oklahoma City
Idaho ID Boise Oregon OR Salem
Illinois IL Springfield Pennsylvania PA Harrisburg
Indiana IN Indianapolis Rhode Island RI Providence
Iowa IA Des Moines South Carolina SC Columbia
Kansas KS Topeka South Dakota SD Pierre
Kentucky KY Frankfort Tennessee TN Nashville
Louisiana LA Baton Rouge Texas TX Austin
Maine ME Augusta Utah UT Salt Lake City
Maryland MD Annapolis Vermont VT Montpelier
Massachusetts MA Boston Virginia VA Richmond
Michigan MI Lansing Washington WA Olympia
Minnesota MN St. Paul West Virginia WV Charleston
Mississippi MS Jackson Wisconsin WI Madison
Missouri MO Jefferson City Wyoming WY Cheyenne
 EST CST MST
Connecticut CT Alabama AL Arizona AZ
Delaware DE Arkansas AR Colorado CO
Florida FL Illinois IL Idaho ID
Georgia GA Iowa IA Montana MT
Indiana IN Kansas KS New Mexico NM
Kentucky KY Louisiana LA Utah UT
Maine ME Minnesota MN
Maryland MD Mississippi MS PST
Massachusetts MA Missouri MO California CA
Michigan MI Nebraska NE Nevada NV
New Hampshire NH North Dakota ND Oregon OR
New Jersey NJ Oklahoma OK Washington WA
New York NY South Dakota SD
North Carolina NC Tennessee TN AST
Ohio OH Texas TX Alaska AK
Pennsylvania PA Wisconsin WI
Rhode Island RI Wyoming WY HST
South Carolina SC Hawaii HI
Vermont VT
Virginia VA
West Virginia WV
District Of Columbia DC

Navy Call List

A Alpha N November
B Bravo O Oscar
C Charlie P Papa
D Delta Q Quebec
E Echo R Romeo
F Foxtrot S Sierra
G Golf T Tango
H Hotel U Uniform
I India V Victor
J Juliet W Whiskey
K Kilo X X-ray
L Lima Y Yankee
M Mike Z Zulu
 Integra Connect AR Follow UP | CALL OPENING & CALL CLOSING SCRIPT

OPENING CALL:

INS: Thanks for calling __________ & how may I assist you?

AR: Hi, my name is calling on behalf of __________ provider’s office, to check on a claim status/eligibility (or
what do you need).

INS: Could you provide me your provider’s name & TAX id/ NPI?

AR: Yes sure, provider’s name is DR._________ & his/her tax id is ___________.

INS: How may I assist you today?

AR: I’m checking/verifying claim status for the pt’s id # ………. & pt’s name is …………..

INS: What is the Date of service and billed amount?

AR: It is ………. (Along with the billed amount)

IF AR WANTS TO SEARCH SOMETHING & PLACING REP ON HOLD

AR: I want to verify that in my system/to pull the info; may I place the call on hold for a moment?

AFTER GETTING THAT INFO

AR: Thank you for being on hold\thank you so much for being on hold.

IF AR REPROCESS OVER THE CALL EXPLAIN THE REASON FOR REPROCESS & THEN REQUEST TO REPROCESS.

IF AR WANT TO VERIFY STATUS FOR MORE CLAIMS

AR: I have few more claims to verify status, if you could help me on those claims?

CLOSING CALL:

AR: Thank you so much for your patience & information. Have a nice day/nice weekend. Good Bye.
 Mock Call Practice Sheet
Provider Details
Provider’s Name : American Medical Response
Rendering Provider : American Medical Response
Pay to Address : P.O. Box- 749667 Los Angeles California – 90074-9667
PIN : GA187 (Aetna)
-------- (UHC)
Tax ID# : 131 64 7834
NPI : 1325648592
Call Back Number : 800-123-4567 Extn # 2345

Patient’s Details:
Patient’s Name : Scott, Amanda
DOB : July 15th 1980
SSN : 883-78-6743
Patient’s Address : 908, Chamber Lane Dallas Texas - 75284
Policy Holder : Scott, Bryan

Payer Details:
Primary Payer : Aetna
Primary Address : P.O. Box- 99211 Dallas Texas – 75284
Payer ID# : 88461
Tel# : 800 679 4579
Primary Policy ID# : W1234578751
Group # : 8946431

Secondary Payer : UHC

Secondary Address : P.O. Box- 4579 Houston Texas – 75211
Payer ID# : 45471
Tel# : 800 456 7893
Secondary Policy ID# : 8156784595

Claim Details:
Date of Service : Oct 10th 2020
Billed Amount : $1055.26

PX Codes : 1. A0427-PH-ALS (Advanced Life Support) - $1008.92

2. A0425-PH-Ground mileage- 2 Miles- $46.34

Emergency : YES
Place of service : 41(Ambulance Land)
Dx Code : AX578.9 Hemorrhage of gastrointestinal tract

From Location : 51 Northeast Grand Ave Dallas TX 75284 TO

To Location : Emmanuel Hospital Dallas TX 75288

Scrubber Report : Claim submitted on Oct 13th 2020