Version 5010 of the X12 HIPAA transaction and code set standards for electronic healthcare transactions. This standard includes transactions for claims, referrals, claim status, eligibility, and remittances. Mandatory compliance date was January 1, 2012. These standards are necessary for the new ICD-10-CM diagnosis codes.
Also referred to as "ObamaCare". A Federal law enacted in 2010 intended to increase healthcare coverage and make it more affordable. It also expands Medicaid eligibility and guarantees coverage without regard to pre-existing medical conditions.
When a healthcare provider accepts as full payment the amount paid on a claim by the insurance company. This excludes patient responsible amounts such as coinsurance or co-pay.
When a claim is corrected which results in a credit or payment to the provider.
The reimbursement amount an insurance company will pay for a healthcare procedure. This amount varies depending on the patient's insurance plan. For 80/20 insurance, the provider accepts 80% of the allowed amount and the patient pays the remaining 20%.
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.
Referrs to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software 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.
Typically services a patient requires in a hospital setting that are in addition to room and board accommodations. Examples: surgery, lab tests, counseling, therapy, etc.
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.
Usually found on the patient statement. This is the amount of the charges, determined by the patient's insurance plan, that the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.
Insurance payments that are paid directly to the doctor or hospital for a patient's treatment. This is designated in Box 27 of the CMS-1500 claim form.
A way for companies to outsource some or all aspects of their information technology needs. It frees a business of the need to purchase, maintain, and backup software and servers.
When a patient requires permission (or authorization) from the insurance company before receiving certain treatments or services.
Person or persons covered by the health insurance plan and eligible to receive benefits.
An organization of affiliated insurance companies (approx. 450), independent of the association, that offer insurance plans within local regions under one or both of the association's brands.
A fixed payment paid per patient enrolled over a defined period of time that is paid to a health plan or provider. This covers the costs associated with the patient's health care services regardless of the number of services provided.
The insurance company or "carrier" the patient has a contract with to provide health insurance.
Category I: Medical procedures/services identified by 5 digit CPT Code.
Category II: Optional performance measurement tracking codes (numeric with letter as last digit).
Category III: Temporary codes assigned for collecting data (numeric followed by letter).
(Civilian Health and Medical Program of the Uniformed Services) Recently renamed TRICARE. Federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.
When medical care is provided at no cost or at reduced cost to a patient that cannot afford to pay.
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.
A service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors to minimize rejections. Clearinghouses electronically transmit claim information compliant with HIPAA standards.
(Centers for Medicaid and Medicare Services) Federal agency which administers Medicare, Medicaid, HIPAA, and other health programs. Formerly known as HCFA.
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 its red ink.
Medical Billing Coding involves taking the doctor's notes from a patient visit and translating them into the proper diagnosis (ICD-9 or ICD-10 code) and treatment (CPT codes). This is for reimbursing the provider and classifying diseases.
Health insurance coverage available to an individual and their dependents after becoming unemployed. Stands for Consolidated Omnibus Budget Reconciliation Act (1986). Coverage typically lasts up to 18 months.
Percentage or amount defined in the insurance plan for which the patient is responsible (e.g., 80/20 ratio where carrier pays 80% and patient pays 20%).
The ratio of payments received to the total amount of money owed on the provider's accounts receivable.
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.
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.
Amount paid by patient at each visit as defined by the insured plan.
(Current Procedural Terminology) A 5 digit code assigned for reporting a procedure performed by the physician. Established by the AMA.
Application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH.
The balance shown in the "Balance" column with a minus sign or parenthesis (e.g., -$50). Indicates the provider may owe the patient a refund.
When claim information is automatically sent from Medicare to the secondary insurance such as Medicaid.
Date that health care services were provided.
Summary of daily patient treatments, charges, and payments received.
Amount patient must pay before insurance coverage begins. E.g., a $1000 annual deductible must be met before insurance pays.
Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.
Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.
When the insurance company reduces the code (and amount) of a claim when documentation doesn't support the level of service submitted.
Request by an insurance company or group medical plan to another insurance company/plan to determine if other coverage exists.
Abbreviation for diagnosis code (ICD-9 or ICD-10 code).
Claim information sent electronically from billing software to the clearinghouse or carrier in a standard electronic format.
Electronic paperless means of transferring money directly to a bank account, eliminating paper checks.
CPT codes 99201 thru 99499 used by physicians to access (or evaluate) a patient's treatment needs.
EMR: Electronic Medical Records (managed at provider location).
EHR: Electronic Health Records (comprehensive collection stored at several locations).
Conversion of data into a form that cannot be easily seen by unauthorized persons. Used for compliance with HIPAA requirements.
Individual covered by health insurance.
Statement from insurance company explaining payment details, covered charges, write offs, patient responsibilities, and deductibles.
Electronic version of an insurance EOB that provides details of claim payments, formatted according to HIPAA X12N 835 standard.
(Employee Retirement Income Security Act of 1974) Law establishing reporting, disclosure, and financial standards for group life and health. Regulates self-insured plans.
Liability insurance for professionals to cover mistakes which may cause financial harm to another party.
Federal law that regulates the collection and use of consumer credit information.
(Fair Debt Collection Practices Act) Federal law regulating creditor or collection agency practices when trying to collect on past due accounts.
Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital.
Cost associated with each CPT treatment billing code for a provider's treatment or services.
The portion of the charges that are the responsibility of the patient or insured.
A Medicare representative who processes Medicare claims.
A list of prescription drug costs which an insurance company will provide reimbursement for.
When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.
A means for one or more employers to provide health benefits or medical care for their employees.
A responsible party and/or insured party who is not a patient.
(Healthcare Common Procedure Coding System) Standardized coding system.
Level I: CPT codes.
Level II: Non-physician items (supplies, ambulatory, etc).
Level III: Local codes for specific state Medicaid/Medicare areas.
Tax exempt account provided by an employer from which an employee can pay health care related expenses.
(Health Insurance Portability and Accountability Act) Federal regulations intended to improve health care efficiency and establish privacy/security laws for medical records.
A type of health care plan that places restrictions on treatments and usually requires staying within a network.
Inpatient, outpatient, or home healthcare for terminally ill patients.
International Classification of Diseases system used to assign codes to patient diagnosis.
ICD-9: 3-5 digit number.
ICD-10: 3-7 digit number, includes more available codes.
Also referred to as fee-for-service. Commercial insurance where the patient can use any provider or hospital.
An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate.
Hospital stay of more than one day (24 hours).
Insurance plan requiring a patient to see doctors and hospitals that are contracted with the managed care insurance company.
The maximum amount the insured is responsible for paying. When reached, insurance typically pays 100% of eligible expenses.
Provision of the 2009 HITECH act providing stimulus money to providers who implement and effectively use Electronic Health Records (EHR).
Health care worker who performs administrative and clinical duties in support of a licensed health care provider.
Analyzes patient charts and assigns appropriate ICD and CPT codes.
Processes insurance claims, ensures correct coding, submits to payers, enters payments, and manages patient statements.
A medical service or procedure performed for treatment of an illness/injury that is not considered investigational, cosmetic, or experimental.
Federal insurance for people over 65 or with restrictions.
Part A: Hospital coverage.
Part B: Physicians visits/outpatient.
Part D: Prescription drugs.
Insurance coverage for low income patients. Funded by Federal and state government and administered by states.
Adds information to a CPT code to indicate a service has been altered. Important for explaining procedures and obtaining reimbursement.
(National Provider Identifier) A unique 10 digit identification number required by HIPAA and assigned through NPPES.
A provider that does not have a contract with the insurance carrier. Patients usually pay a greater portion of charges.
Treatment in a physician's office, clinic, or day surgery facility lasting less than one day.
Used on claims (e.g., CMS 1500 block 24B). A two digit code defining where procedure was performed (11=Office, 12=Home, 21=Inpatient).
Commercial insurance plan where the patient can use any doctor or hospital within the network.
Requirement for primary doctor to notify insurance carrier of certain procedures for them to be covered.
The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.
Individual identifying information (name, address, SSN) and information pertaining to healthcare diagnosis or treatment.
When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).
Document supplied by the payer with information on claims submitted, including explanations for denials. Also called EOB.
Process of checking an insurance claim for errors in the software prior to submitting to the payer.
Claim for insurance coverage paid after the primary insurance makes payment. Covers gaps in coverage.
A nursing home or facility for convalescence providing specialized care for long-term or acutely ill patients.
The form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes ICD and CPT codes.
Federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly CHAMPUS.
Claim form for hospitals, clinics, or any provider billing for facility fees. Replaces the UB92 form.
Illegal practice of assigning a diagnosis code that doesn't agree with patient records to increase reimbursement.
Allowable coverage limits determined by the insurance company to limit the maximum amount they will pay for a given service.
Insurance claim that results from a work related injury or illness.
The difference between physician charges and what the insurance plan allows, which the patient is not responsible for. Also referred to as "not covered".
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