MADHAV

CONSULTANCY&TRANING SERVICES

STUDENT NAME :………………………….

MADHAV TRANING SERVICES

1ST Vishnu Mansion Venkateswara swamy temple
Back side Rd, SR nagar ,HYD
MADHAV
Consultancy & training services

"Connecting talent with opportunity, we bridge the gap

between aspirations and achievements. Your success is
our business – let's build your career together."
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Medical Billing Terminologies

Account Number/Encounter number – Number given by doctor or hospital for each and every
patient’s medical visit to track what is the i) medical condition, ii) treatment rendered, iii) Cost of the
treatment rendered for that particular date of service. Block # 26 on CMS 1500.

Advance Beneficiary Notice (ABN) – A notice the hospital or doctor gives the patient before the
treatment, telling the patient that Medicare may 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.

Adjudication – This is when we compare your benefits to a claim you or your doctor submitted for a
health care service (example: office visit). It helps us figure out if the doctor is charging the right
amount, what portion we pay and what portion you pay.

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 has 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.

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. The AMA also publishes a list of Physician Specialty Codes
which are the standard method in the U.S. for identifying physician and practice specialties.

Ambulatory Surgery (ASC) – Outpatient surgery or surgery that does not require an overnight
hospital stay. Also known as “Day surgery” or “Same Day Surgery” or “Short Procedure Unit” or
“SDS”. Ex: Eye Laser Therapy.

Ancillary care – Health care services like lab tests, X-rays, rehab, hospice care and urgent care.
They’re not necessarily performed by doctors, but help doctors diagnose or treat a health condition.

Allowed amount / considered amount/Approved amount – The dollar amount an insurance

company deems fair for a specific service or procedure.

Appeal – A process by which patient or doctor/hospital can object if they disagree with the
insurance processing.

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. It is
120 days for Medicare & other insurance it varies.

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Assignment of Benefits (AOB) – A written consent, signed by the policyholder / patient (in the
absence of the policyholder) at the time of registration. This is to an insurance company, to pay
benefits directly to the providers. Block # 13 on CMS 1500 form should have the phrase “SIGNATURE
ON FILE”. If not found, then the claim will be paid to the patient & not to the provider.

Authorization Number –The system whereby a provider must receive approval from a staff member
of the health plan, such as the health plan Medical Director in the UMR Department (Utilization
Management Review), before a member can receive certain health care services. It relates not only
whether a service of the procedure is covered but also to find out whether it is medically necessary.
Also called as Certification Number/ Prior–Authorization Number / Pre–certification / Pre–admission
approval. It’ll be in the Block # 23 on CMS 1500.

Back Dating the Prior Authorization– If authorization is not used in that particular date & if the
service is postponed, request can be sent to insurance to use the same auth. If insurance accepts
then it can be used. Need to explain why authorization not used at the proper time.

Balance Billing– If the patient is enrolled with the secondary payer then the balance is billed to it. If
the patient is not enrolled with the secondary payer then the balance is billed to the patient. This is
called Balance billing.

Bankruptcy – Bankruptcy is a legal proceeding where an insolvent person can be relieved of financial
obligations, but loses control over bank accounts, and future financial options. Bankruptcy is a last
resort for those with debt problems, and although while it may wipe the slate clean (to some extent)
in terms of debt, it is extremely harmful to your credit rating, and will no doubt affect the way you
are handled by financial organizations in the future. Patient can’t be billed & look for next insurance
or else need to wait.

Benefits – These are the health care services and supplies we cover for you when you’re a member.
For example, if you have health care benefits with us, we help cover the cost of the health care you
get.

Beneficiary – Person covered by health insurance (enrollee or insured or subscriber or member) or

who enjoys benefits may be “covered” or “dependents”.

Benefit Period – From the start date to the end date of your coverage. During this time, if you get
care, we cover the portion of the cost we’ve agreed to.

Beneficiary Eligibility Verification (BEV) – A way for doctors and hospitals to get information about
the patient’s insurance coverage / benefits.

Billed amount of the claim/Charge amount of the claim– It is the Amount charged for each service
performed by the provider. In other words it is the total charge value of the claim. The billed amount
for a specific procedure code is based on the provider. It may vary from place to place. It is not
common across all the states.

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Billing Office – The office which maintains the financial transactions of the provider. Eg: Omega
HealthCare.

Birthday rule – Birthday rule is a rule in determining the primary and secondary insurance for a child
when the parents are insured. It is calculated as per coverage of the parent whose birthday (month
and day, not year) comes first in the year is considered to be your children's primary coverage.

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 Per Member Per Month (PMPM). In other words, specified amount paid periodically to health
provider for a group of specified health services, regardless of quantity rendered.

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

CDM– Charge Description Master – Inbuilt software where all billed amount for procedure codes are
listed.

CDT (Current Dental Terminology) – CPT codes for dental services.

Charity Care: Free medical care given to patients in financial difficulty who cannot afford to pay.

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

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

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

CLIA – Clinical Laboratory Improvement Amendments – 10 digits. It’ll be in the block # 23 on CMS
1500.

CMS 1500 – This is the form that doctors use to submit a claim to the insurance company. It has 33
blocks. Other names are Provider claim/Medical claim/Professional Component/Provider Bills/
Medical bills/Professional claims.

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.

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Coinsurance – A percentage of the allowable amount which the patient is responsible to pay.

Collection Agency – A business that collects money for unpaid bills.

Contractual Adjustment (Discount) – The part of the bill that doctor or hospital must write off (not
charge patient) because of billing agreements with the patient’s insurance company. This is only for
contracted providers.

Coordination of Benefits (COB) – A way to decide which insurance company is responsible for
payment if the patient has more than one insurance plan. This should be updated by the patient to
provider’s office and also the insurances.

Co–pay – A small, fixed amount a patient directly pays a provider for specific services. It is an upfront
payment a patient has to pay every time a patient visits a physician or Hosp. Also called “FLAT RATE”
fee that is assigned as the out of pocket cost to see a par provider as each encounter.

Covered Expenses – Covered services are those medical procedures the insurer agrees to pay for.
They are listed in the policy.

CPT (Current Procedural Terminology) – codes used to report services and procedures. These are
level I codes under HCPCS.

CPT modifier – A two character numeric descriptor used only with CPT codes.

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.

Date of Service – The date (s) when the patient was treated.

Deductible – A fixed amount per contractual period that a pt pays before health insurance will begin
to pay; this is only paid if provider services are obtained. The patient has to meet the Deductibles
every year.

Demographics (Patient Demographics–PD) – Physical characteristics of a patient such as age, sex,

address, etc. necessary for filing a claim. Also called as Demo sheet / Face sheet.

Dependent – Members of the subscriber’s family, like a child or spouse, who are eligible for benefits
under their health plan.

Diagnosis code – 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.

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Dis-enroll/Disenrollment – When a member leaves a health benefit plan. The opposite of

enroll/enrollment.

Durable Medical Equipment (DME) – Medical equipment that can be used many times, or special
equipment ordered by your doctor, usually for use at home. Ex: Wheelchair.

E Codes –codes used to describe external causes of injury, poisoning, or other adverse reactions
affecting the patient’s health. This will be the secondary dx always.

Effective Date – The date your health coverage or benefits begin.

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.

EMR (Electronic Medical Records)/EHR (Electronic Health Records)–This is a patient’s medical record
in digital/electronic format.

Emergency Care – Care given for a medical emergency when the patient's health is in serious danger
when every second counts. Pre–certification or Authorization is not necessary for ER services. Block
# 24 C marked as “Y” which is called Emergency indicator. If not mentioned it will be denied by
insurance even if the POS mentioned as ER/23.

Enrollee / Guarantor / Subscriber / Policy holder / Insured – A person who is the ‘owner of the
policy’ or ‘purchases the policy’ or ‘pays premium’.

E/M Services: Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes are
codes used by a physician to report services including but not limited to patient history, examination,
and/or medical decision making. These services are divided into broad categories such as office
visits, hospital visits, and consultations.

Explanation of Benefits / Electronic Remittance advice/Remittance Advice (EOB/ERA/RA) – The

notice sent to the patient and the doctor from the patient's insurance company after processing
claims explaining the status. Medicare EOB is called as EOMB.

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

Federal Tax ID Number – A number assigned by the federal government to doctors and hospitals for
tax purposes. Block # 25 on CMS 1500. The format is 3–2–4.

Fee for Service– This plan existed before MCOs. With fee for service, the doctor sent the claim. If the
charge was $100, the insurance company paid $100. Indemnity plans are almost extinct with many
insurance companies.

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Fee schedule – A listing of the allowed amount that an insurer or health plan will pay for a service
based on the PX code.

Flexible Spending Account (FSA) – A special account that allows you to set aside tax-free money, to
use on qualified health care or dependent care expenses.

Food and Drug Administration (FDA) – The US government agency that enforces the laws on the
manufacture, testing and/or use of drugs and medical devices.

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.

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.

Primary Care Physician: Primary care physician (PCP) is also called as Gate Keeper & also as referring
physician or referring doctor or referring provider. He regulates the patient to the specialist who is in
the network. On CMS 1500, Name is in the block # 17, NPI # 17b, and Group # 17a.

Global payment (Bundled Physician Rates) – Payment for provider & hospital are bundled i.e.,
includes both the professional & the technical component if same provider send both the bills.

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 allowed
separately. For major surgery it is 90 days & for minor surgery it is 10 days.

Grievance – An official complaint about your service or benefits. You can file a grievance by calling
the number on the back of your ID card.

Group – An employer, association or trust that offers health coverage to its members or employees.

HCPCS – A coding system used to report procedures, services, supplies, medicine, and durable
medical equipment.

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

Health Benefit Plan – Health coverage may be called your health plan, health benefit plan, health
coverage plan, these are all ways to describe a policy that helps you pay for your health care. Each
plan is different. To see the ways your health benefit plan covers you log in and look over your
benefits.

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Health care services – Anything that a doctor or other health care provider does for you to help you
with your health. Includes check-ups, treatments, care you get in a hospital and more.

HIPAA (The privacy rule/Act of 1996) – Health Insurance Portability and Accountability Act. This
federal act sets standards and 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.

HMO (Health Maintenance Organization) – Must use the doctors and hospitals designated by the
HMO. Need PCP & he’ll be capitated under the insurance. Referral #/ referral letter is must. OON
benefits not covered.

Health Reimbursement Account (HRA) –An account of money set up and funded by your employer.
You can use the money to pay your health care costs, until your plan starts paying a bigger share —
after you meet your deductible. It’s a type of consumer-driven health plan (CDHP).

Health Savings Account (HSA) – A bank account you can use to pay for health expenses. You or your
employer can put tax-free money into your HSA. You’ll use that money to pay for your share of care
costs, like your deductible or coinsurance. If you don’t use all the money, it stays in there next year
and beyond. You can also take it with you if you change health plans.

Home Health Care –Care given by a home health agency to you at your home. It’s most often if
you’re disabled, sick or convalescent.

Hospice –A facility or service that gives care to terminally ill patients, as well as support to the family.
The care is often for controlling pain and other symptoms, and can be provided in the home or in an
inpatient setting.

Hospital –A center where you go when you need care or surgery. You may go to a hospital, get your
treatment and then go home that day (outpatient). Or your condition or the care you need may
require you to stay over for one or more nights (inpatient).

Identify – To find or recognize.

Individual plan –A health coverage plan you buy on your own, not through your job or another type
of group. It can also include your family or other qualified dependents.

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

Insurance company – An organization contracted with patient to pay for his health care expenses.
Also known as insurer or health plan.

Insured – One who has or is covered by an insurance policy.

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Insured Group Name – Name of the group or insurance plan that insures the patient, usually an
employer.

Insured Group Number – A number that your insurance company uses to identify the group under
which the patient is insured.

Internal Control Number (ICN) / Document Control Number (DCN)/Claim Control Number – A
number assigned to the bill/claim by the insurance company as soon as they receive a claim in their
system. Medicare’s claim # is called as TCN (Transaction control Number).

In Process – The claim is received by the insurance company and is being reviewed.

IPA – Independent Practice Association. An organization of physicians that are contracted with a
HMO plan.

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.

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

Lifetime Maximum – The maximum amount of benefits your health plan carrier will pay for your
lifetime, not just for a plan year.

Litigation–The period where the case is in the court is called Litigation. Ex: No fault insurance,
Worker’s compensation. Patient can’t be billed till the case gets over; other insurance can be billed if
patient has. Need to wait for response from the court.

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

Limiting Charge– When a doctor does not accept assignment, there are limits on the amount he or
she can charge you for most services. The doctor is allowed to charge 115 % of what Medicare
approves. This is referred to as the limiting charge.

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.

LMRP (Local Medical Review Policy) – LMRPs have been defined by CMS as "an administrative and
educational tool to assist providers, physicians, and suppliers in submitting correct claims for
payment" within a specified geographic area. However, the major goal of these local policies is to
prevent overutilization of clinical services paid by CMS. Their impact on providers and beneficiaries
can be limiting coverage or to deny claims outright. Now they are divided into 2, one is called as LCD
(Local coverage Determination) & the other one is NCD (National Coverage Determination). URL is
http://cms.gov/medicare–coverage–database/

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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.

Manual claims submission – the process of submitting health insurance claims via mail.

Medical Recording Index no (MRI) – It's maintained for 3 years in the sense after 3 years from the
last visit to the doctor, then he is considered as New Patient. The others are called Established
Patient. After this, an account no. is given each visit is given a New A/C no.

Medical Record Number – The number assigned by your doctor or hospital that identifies your
individual medical record.

Medicaid –A government program that provides health coverage to some citizens who are younger
than 65 years of age who can’t afford private health insurance.

Medicare –A government program which provides health coverage to people 65 years or older.

Medical group –A company made up of doctors and other health care providers who work together
to care for patients.

Mother baby clause – Mother Baby clause is a 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.

Medicare Automated Cross over Claim– When claim information is automatically sent from
Medicare the secondary insurance such as Medicaid.

Medicare Advantage Plan (Part–C/Medicare HMO/Medicare Managed Care)–Additional benefits

provided by the private plan along with Part A and Part B benefits. They work based on the Medicare
guidelines. The patient cannot go for Medi-gap when he is enrolled in Part C.

Medical Necessity – This term refers to healthcare services or treatments that a patient requires to
treat a serious medical condition or illness. This does not include cosmetic or investigative services.

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.

Medicare Summary Notice (MSN) –The notice received by the patient and doctor from Medicare
after processing of claims. It states, the amount billed to Medicare, Medicare's approved payment,
the amount Medicare paid, and the amount to be paid by the patient. It also states denials if any.

Medi-gap–A Medi-gap policy is a health insurance policy sold by private ins companies to fill in the

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“GAPS” in coverage under the original Medicare plan, like deductibles, co–ins & co–payments. Some
Medigap policies also cover benefits that Medicare doesn’t cover, like emergency health care while
traveling outside the US. If pt has a Medicare Advantage plan, then this will not pay anything. They
are Medicare’s supplemental ins. Eg: AARP.

Mental or behavioral health –The health of your mind and emotions, including substance abuse
issues.

Mental Health Services –Care to address the health of the mind and emotions. May include therapy,
medication, day treatment intensive, day rehabilitation, crisis intervention, crisis stabilization,
treatment for substance abuse and more.

Modifier – A modifier is a code added to the PX if there is any alteration/specification of the

treatment/services rendered to the patient.

NDC (National Drug Code)–Drug products are identified and reported using a unique, three–
segment number, identifies the Labeler, product, and trade package size. The NDC will be in one of
the following configurations: 4–4–2, 5–3–2, or 5–4–1. CMS block # 23.

National Provider Identifier (NPI) – a 10–digit, intelligence–free, the numeric identifier for providers
and suppliers issued by CMS. HIPAA mandates the usage of NPI.

Network of Providers/Group Name: Under a same plan, a group of participating providers are there,
they are called as Network of Providers.

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.

Non–Participating Provider (Out Of Network provider/OON/Non–Par/Non–contracted providers) –

A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or
hospital network.

NCCI (National Correct coding Initiatives) – is a CMS program designed to prevent improper
payment of procedures that should not be submitted together.
The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient
hospital services.
The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have
been combined into one table and include code pairs that should not be reported together for a
number of reasons explained in the Coding Policy Manual.

URL: http://cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI–Coding–Edits.html

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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.

OIG (Office of Inspector General) – Part of Department of Health and Human Services. Establish
compliance requirements to combat health care fraud and abuse. Have guidelines for billing services
and individual and small group physician practices.

Onset Date–Starting Date of illness/treatment.

Out–of–Pocket Costs – the patient’s share of the cost of health care services. This can include co–
payment, co–insurance, or deductible.

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

Over the Counter Drug – Drugs not needing a prescription that you buy at a pharmacy or drug store.

Offset – When an insurance company makes a wrong / excess payment to its providers, it would
adjust the amount in its subsequent claims. This is called an offset. Refund is called as Recoupment.

Ordering physician: He is a physician who orders for non–physician services for the patient such as
diagnostic laboratory tests, clinical lab tests, pharmaceutical services & durable medical equipment.
Block # 17.

Participating Provider (In–network provider/Par provider/Contracted providers) – A doctor or

hospital who has contracted with the insurance company, has agreed to certain terms and payment
conditions set by the insurance plan.

Payer id– It is an electronic mailing address to send claims electronically but not the e–mail. It is 5
digits in number. Ex: the path to find payer id list is https://access.emdeon.com/PayerLists/

PTAN (Provider Transaction Access Number) – It is given by Medicare to their par provider which is
also called as “Legacy provider identification number” or also “Medicare Pin”.

Place of Service – This designates where the actual health services are being performed, whether it
is home, hospital, office, and clinic.

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

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.

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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 use other doctors, but at a higher cost.

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.

Pre–registration– The function of this department can be categorized into three. They are i)
Scheduling the patient’s visit, ii) Collecting all the demo details, iii) Insurance Eligibility Verification.

Premium – Amount paid periodically by Patient to keep the health insurance plan active.

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

Pre-Certification –For some health care services, you or your doctor needs to let us know about it
ahead of time. We ask this so we can check whether it’s covered by your plan. During this step, we
may also double check that it makes sense and does not conflict with other care you’re getting, or
medications you’re taking.

Preventive Care –Tests or treatments that may help you stay healthy or catch problems early on
when they’re easier to treat.

Procedure code – The code used to describe the services / treatment provided by the doctor /
hospital. Short form is PX.

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

Provider Identification Number (PIN) – Assigned by the Insurance company / health plan to their
contracted providers. It is unique to each carrier & no specific format.

Rebill – To resubmit a claim.

Referral – A reimbursement requirement of some payers where by a PCP must first refer a pt before
the second provider’s services will be covered. A pt needs to make sure that PCP issues a “referral”
before she/he can visit a specialist or hospital. Box # 23

Reprocess–If denial is incorrect & request insurance rep to process the claim over the phone is called
as Reprocessing.

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Release of Information (ROI) – A signed statement from patients or guarantors that allows doctors
and hospitals to release medical information to the entities who all are involved in the billing cycle.
This is intimated to the insurance through “Signature on File” (SOF) on CMS 1500 block # 12.

Retro Authorization: Only in emergency or certain contains the provider can get the retro
authorization. Getting authorization after rendering the services within a prescribed of time or day,
then it is called as retro– authorization no. Time period varies from insurance to insurance.

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

Specialist – A doctor who specializes in treating certain parts of the body or specific medical
conditions. For example, cardiologists only treat patients with heart problems. Also called as
“Rendering provider” or SCP or “Attending physician” or “treating physician”.

Self-Pay– The patient with no insurance is called as Self pay and they are responsible for the bills.

Stop–loss clause (or) Catastrophic Limit: The insurance company fixes the slab amount if the payee
reaches the amount and the patient need not to pay.

Super bill –a form listing procedure, service and diagnosis codes used to record services performed
for the patient and the patient’s diagnosis for a given visit.

Supplemental – A supplemental plan usually picks up the patient’s deductible and/or co–insurance,
copay. This name is for Commercial & Medicare it is called as Medigap.

Timely filing limit – The time frame that payers give to providers to submit the claims and get
reimbursed. It is calculated from Date of service. For Medicare it is 1 yr & other insurance it varies.

Third Party Administrator (TPA) – An independent corporate entity or person (third party) who
administers group benefits, claims and administration for a self–insured company or group.

UB–92 / UB–04 (Uniform billing 92 / 04) / CMS 1450 – A form used by hospitals to file insurance
claims for medical services. It has blocks 81. Also known as Hospital claims/Technical
Component/Institutional claims/Facility Claims/Hospital Bills.

UCR – Usual and customary Reasonable – 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.
Units of Service – Measures of medical services, such as the number of hospital days, pints of blood,
kidney dialysis treatments, etc.

UPIN – Unique Physician Identification Number. 6 digit physician identification number created by
CMS. Discontinued in 2007 and replaced by NPI number.

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Utilization Review/Utilization Management/Case Management (UR\UM\UMR) – 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.

V Codes – ICD–9 (diagnosis) codes assigned for preventive medicine services and for reasons other
than disease or injuries.

Waiting Period: It is a length of the time given by the insurance company to the patient for pre–
existing condition. It may range from 6–18 months from the effective date of the policy.

Waiver of Liability: It is a document, signed by the patient, stating that, in case of insurance is not
going to pay, or not covering the payment, the patient himself is liable for the payment. This is for
commercial insurances.

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.

W–9 Form – A tax form which certifies an individual's tax identification number. Helps to update
provider’s contract, provider’s mailing address & sometimes helps to verify credentials also. Some
insurance will update all the details every year; need to produce W9 form that time. If not updated,
then the claim will be denied for W9 form. (Comes under the denial–pended/denied for additional
information).

MADHAV TRANING SREVICES 14

CHAPTER 2
 L E
P
A M
S
PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
 L E
P
A M
S
PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
 CARRIER
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
PICA PICA

1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED’S I.D. NUMBER (For Program in Item 1)
HEALTH PLAN BLK LUNG
(Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE SEX 4. INSURED’S NAME (Last Name, First Name, Middle Initial)
MM DD YY
M F
5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street)

Self Spouse Child Other

CITY STATE 8. RESERVED FOR NUCC USE CITY STATE

PATIENT AND INSURED INFORMATION

ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)

( ) ( )
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX
MM DD YY
YES NO M F
b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? b. OTHER CLAIM ID (Designated by NUCC)
PLACE (State)
YES NO
c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO If yes, complete items 9, 9a and 9d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for
to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment services described below.
below.

SIGNED DATE SIGNED

14. DATE OF CURRENT ILLNESS, INJURY or PREGNANCY (LMP) 15. OTHER DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM DD YY MM DD YY MM DD YY MM DD YY
QUAL. QUAL. FROM TO
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
17b. NPI FROM TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? $ CHARGES

YES NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E) 22. RESUBMISSION
ICD Ind. CODE ORIGINAL REF. NO.
A. B. C. D.
23. PRIOR AUTHORIZATION NUMBER
E. F. G. H.
I. J. K. L.
24. A. B. E. F. G. H. I. J.

PHYSICIAN OR SUPPLIER INFORMATION

DATE(S) OF SERVICE C. D. PROCEDURES, SERVICES, OR SUPPLIES
From To DAYS EPSDT
PLACE OF (Explain Unusual Circumstances) DIAGNOSIS OR Family ID. RENDERING
MM DD YY MM DD YY SERVICE EMG CPT/HCPCS MODIFIER POINTER $ CHARGES UNITS Plan QUAL. PROVIDER ID. #

1 NPI

2 NPI

3 NPI

4 NPI

5 NPI

6 NPI
25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd for NUCC Use
(For govt. claims, see back)
YES NO $ $
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( )
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)

SIGNED DATE
a.
NPI b. a.
NPI b.

NUCC Instruction Manual available at: www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
CHAPTER 3
UB-04 claim form and instructions
The Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04
claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider
Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient
claims can be found on pages 3 and 4.

The UB-04 claim form and NPI

The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form
accommodates the NPI, you may continue to report your current provider identification numbers in the
appropriate areas of the form until otherwise notified. If you have obtained your NPIs and submitted them to us,
you must report them on the UB-04 claim form.
If you have any questions regarding the UB-04 claim form, the NPI application process, or reporting your NPI to
us, please call your Network Coordinator or Hospital/Ancillary Services Coordinator or contact Customer Service
at 1-800-275-2583.

UB-04 data field requirements

Field location
Description Inpatient Outpatient
UB-04
1 Provider Name and Address Required Required
2 Pay-To Name and Address Situational Situational
3a Patient Control Number Required Required
3b Medical Record Number Situational Situational
4 Type of Bill Required Required
5 Federal Tax Number Required Required
6 Statement Covers Period Required Required
7 Future Use N/A N/A
8a Patient ID Situational Situational
8b Patient Name Required Required
9 Patient Address Required Required
10 Patient Birthdate Required Required
11 Patient Sex Required Required
12 Admission Date Required Required, if applicable
13 Admission Hour Required Required, if applicable
14 Type of Admission/Visit Required Required
15 Source of Admission Required Required
16 Discharge Hour Required N/A
17 Patient Discharge Status Required Required
18-28 Condition Codes Required, if applicable Required, if applicable
29 Accident State Situational Situational
30 Future Use N/A N/A
31-34 Occurrence Codes and Dates Required, if applicable Required, if applicable
35-36 Occurrence Span Codes and Dates Required, if applicable Required, if applicable
37 Future Use N/A N/A
38 Responsible Party Name and Address Required, if applicable Required, if applicable
39-41 Value Codes and Amounts Required, if applicable Required, if applicable
42 Revenue Code Required Required
43 Revenue Code Description Required Required
NDC Code Required, if applicable Required, if applicable

AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey •

QCC Insurance Company d/b/a AmeriHealth Insurance Company
12.09 1
Field location
Description Inpatient Outpatient
UB-04
44 HCPCS/Rates Required, if applicable Required, if applicable
45 Service Date N/A Required
46 Units of Service Required Required
47 Total Charges (By Rev. Code) Required Required
48 Non-Covered Charges Required, if applicable Required, if applicable
49 Future Use N/A N/A
50 Payer Identification (Name) Required Required
51 Health Plan Identification Number Situational Situational
52 Release of Info Certification Required Required
53 Assignment of Benefit Certification Required Required
54 Prior Payments Required, if applicable Required, if applicable
55 Estimated Amount Due Required Required
56 NPI Required Required
57 Other Provider IDs Optional Optional
58 Insured’s Name Required Required
59 Patient’s Relation to the Insured Required Required
60 Insured’s Unique ID Required Required
61 Insured Group Name Situational Situational
62 Insured Group Number Situational Situational
63 Treatment Authorization Codes Required, if applicable Required, if applicable
64 Document Control Number Situational Situational
65 Employer Name Situational Situational
66 Diagnosis/Procedure Code Qualifier Required, if applicable Required, if applicable
Principal Diagnosis Code/Other Diagnosis
67 Required Required
Codes
68 Future Use N/A N/A
69 Admitting Diagnosis Code Required Required, if applicable
70 Patient’s Reason for Visit Code Situational Situational
71 PPS Code Situational Situational
72 External Cause of Injury Code Situational Situational
73 Future Use N/A N/A
74 Principal Procedure Code/Date Required, if applicable Required, if applicable
75 Future Use N/A N/A
76 Attending Name/ID-Qualifier 1G Required Required
77 Operating ID Situational Situational
78-79 Other ID Situational Situational
80 Remarks Situational Situational
81 Code-Code Field/Qualifiers
*0-A0 N/A N/A
*A1-A4 Situational Situational
*A5-AB N/A N/A
AC - Attachment Control number Situational Situational
AD-B0 N/A N/A
*B1-B2 Situational Situational
*B3 Required Required

2 12.09
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 __
INPATIENT __ __

Any Hospital Any Hospital 1234

1 2 3a PAT. 4 TYPE
CNTL # OF BILL

123 Any Street 456 Any Street

b. MED .
REC . # 98765 0111
__

Anytown NJ 08999 Anytown NJ 08999

6 ST ATEMENT CO VERS PERIOD 7
5 FED. TAX NO.
F R OM TH R OUGH
RESERVED
221234567 11 03 06 11 04 06
8 PATIENT NAME a Patient ID if different from Sub 9 PATIENT ADDRESS a 1234 Main Street
b Doe, John b Anytown c NJ d 08999 Country
e code if
ADMISSION CONDITION CODES 29 AC DT 30
other than USA
10 BI R TH DATE 11 SEX 16 DHR 17 ST AT
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28 ST ATE

03 20 1971 M 11 03 06 08 3 3 12 01 Co n d i t i o n Co d e s R e q u i re d I d e n t i f yi n g Eve n t s PA RESERVED

31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE S PAN 36 OCCURRENCE S PAN 37
COD E DATE CODE DATE CODE DATE COD E DATE CODE F R OM THR OUGH COD E F R OM TH R OUGH

FUTURE
Occurrence and Occurrence Span Codes may be used to define a significant event that may affect payer processing
a a

b USE b

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES

CODE AMOUNT CODE AMOUNT COD E AMOUNT
John Doe a A1 952 00
1234 Main Street b Value Codes and amounts required when necessary to process claim
Anytown, NJ 08999
c
d
42 RE V. C D. 43 DESCRIPTION 44 HCPCS / R ATE / HIPPS CODE 45 SE R V. DATE 46 SE R V. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

1
0129 Semi-Private 200.00 2 400 00 0 00 Future
1

2 0250 Pharmacy 1 50 00 0 00 Use 2

3 0360 OR Services 100 00 0 00 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22

23
PAGE 1 OF 1 CREATION DATE TOTALS 550 00 0 00 23

2222222222
52 REL . 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 ES T. AMOUNT DUE 56 NPI
INFO BEN.

AmeriHealth Report HIPAA National Y Y Required when 1234567890

Amount
A 57 A

Health Plan Identifier indicated payer has

B Secondary Payer paid amount to estimated OTHER Secondary B

when mandatory to be due

C
Tertiary Payer Provider PR V ID Tertiary C

58 INSURED ’S NAME 59 P. REL 60 INSURED ’S UNI QUE ID 61 G R OUP NAME 62 INSURANCE G R OUP NO.

A Doe, John 18 ABC1234567800 Watch Repair, Inc. 1234 A

B
Secondary B

C Tertiary C

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTR OL NUMBER 65 EMPLOYER NAME

A
02468 491234 Watch Repair, Inc. A

B Secondary B

C Tertiary C

66
DX 3910
67 A Use A through
B Q to report
C “Other Diagnosis”
D if applicable
E F G H 68
Reserved
9 I J K L M N O P Q
69 ADMIT
DX 4280
70 PATIENT
REASON DX May be
a used to report
b reason forc visit 71 PPS
COD E DRG 72
EC I May be
a used to reportbexternal causecof injury 73
Reserved
74 PRINCIPAL P R OCEDURE
CODE DATE
a. OTHER P R OCEDURE
CODE DATE
b. OTHER P R OCEDURE
CODE DATE
75
76 ATTENDING NPI 2222222222 QUAL G 2 1 23 4 5 6 9 8 2 2
3749 11 03 06 Reserved LAST S m it h FI RST D av i d
c. OTHER PR OCEDURE d. OTHER PROCEDURE e. OTHER P R OCEDURE QUAL
CODE DATE CODE DATE CODE DATE 77 OPER ATING NPI

LAST FI RST

80 REMARKS
81CC
a B3 282N00000X 78 OTHER NPI QUAL

May be used to report additional b Secondary LAST FI RST

information. c Tertiary 79 OTHER NPI QUAL

d LAST FI RST
UB-04 CMS-1450 APPROVED OMB NO . THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
™ National Uni form
LIC9213257

3
Red = Required
Black = Situational/Required, if applicable/Reserved
12.09
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 __
OUTPATIENT __ __

4 TYPE
1
Any Hospital 2
Any Hospital
3a PAT.
CNTL # 1234 OF BILL

123 Any Street 456 Any Street

b. MED .
REC . # 98765 0131
__

6 ST ATEMENT CO VERS PERIOD 7

Anytown NJ 08999 Anytown NJ 08999 5 FE D. TAX NO.
F R OM TH R OUGH
RESERVED
221234567 11 03 06 11 04 06
8 PATIENT NAME a Patient ID if different from Sub 9 PATIENT ADDRESS a 1234 Main Street
b Doe, John b Anytown c NJ d 08999 Country
e code if
ADMISSION CONDITION CODES 29 AC DT 30
other than USA
10 BI R TH DATE 11 SEX 16 DHR 17 ST AT
12 DATE 13 HR 14 TYPE 15 SRC 18 19 20 21 22 23 24 25 26 27 28 ST ATE

03 20 1971 M 11 03 06 08 3 3 12 01 Co n d i t i o n Co d e s R e q u i re d I d e n t i f yi n g Ev e n t s PA RESERVED
31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE S PAN 36 OCCURRENCE S PAN 37
COD E DATE CODE DATE CODE DATE COD E DATE CODE F R OM THR OUGH COD E F R OM TH R OUGH
a FUTURE a
Occurrence and Occurrence Span Codes may be used to define a significant event that may affect payer processing USE
b b

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES

CODE AMOUNT CODE AMOUNT COD E AMOUNT
John Doe a A1 952 00
1234 Main Street b Value Codes and amounts required when necessary to process claim
Anytown, NJ 08999
c
d
42 RE V. C D. 43 DESCRIPTION 44 HCPCS / R ATE / HIPPS CODE 45 SE R V. DATE 46 SE R V. UNITS 47 TOTAL CHARGES 48 NON-CO VERED CHARGES 49

1
0310 Laboratory N400093723106 88173 11 03 06 1 100 00 0 00 Future
1

2
0402 Ultrasoud 76942 11 04 06 1 100 00 0 00 Use 2
3
0360 OR Services 3749 11 04 06 1 100 00 0 00 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22

23
PAGE 1 OF 1 CREATION DATE TOTALS 300 00 0 00 23

2222222222
52 REL . 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 ES T. AMOUNT DUE 56 NPI
INFO BEN.

AmeriHealth Report HIPAA National Y Y Required when 1 2 3 4 5 6 7 8 90

Amount
A 57 A

Health Plan Identifier indicated payer has

B Secondary Payer paid amount to estimated OTHER Secondary B

when mandatory to be due

C
Tertiary Payer Provider PR V ID Tertiary C

58 INSURED ’S NAME 59 P. REL 60 INSURED ’S UNI QUE ID 61 G R OUP NAME 62 INSURANCE G R OUP NO.

A Doe, John 18 ABC1234567800 Watch Repair, Inc. 1234 A

B
Secondary B

C Tertiary C

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTR OL NUMBER 65 EMPLOYER NAME

A
02468 491234 Watch Repair, Inc. A

B Secondary B

C Tertiary C

66
DX 67
3910 A B Q to report
Use A through C “Other Diagnosis”
D E
if applicable F G H 68
Reserved
9 I J K L M N O P Q
69 ADMIT
DX 4280
70 PATIENT
REASON DX a used to report
May be b reason forc visit 71 PPS
COD E DRG 72
EC I a used to reportbexternal causecof injury
May be
73
Reserved
74 PRINCI PAL P R OCEDURE
CODE DATE
a. OTHER P R OCEDURE
CODE DATE
b. OTHER P R OCEDURE
CODE DATE
75
76 ATTENDING NPI 2222222222 QUAL G2 1234569822
3749 11 04 06 Reserved LAST Smith FI RST D av i d
c. OTHER PR OCEDURE d. OTHER PROCEDURE e. OTHER P R OCEDURE QUAL
CODE DATE CODE DATE CODE DATE 77 OPER ATING NPI

LAST FI RST

80 REMARKS
81CC
a B3 282N00000X 78 OTHER NPI QUAL

May be used to report additional b Secondary LAST FI RST

information. c Tertiary 79 OTHER NPI QUAL

d LAST FI RST
UB-04 CMS-1450 APPROVED OMB NO . THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
NUBC
™ National Uni form
Billing Committee LIC9213257

4
Red = Required
Black = Situational/Required, if applicable/Reserved
12.09
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CHAPTER 4
 CHAPTER 4

• HIPAA : It stands for HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT

It started in the 1996 & it got implemented in 1997 &made mandatory from 2003 This also
called as KASSEBUR ACT.

• PHI : PROTECTED HEALTH INSURANCE

It has four rules

1. Standards in transactions

2. Unique identifiers

3. Privacy rule {to protect the privacy rights of the patient }

4. Security rule

• P’P’P :
1. Provider : Someone who gives the treatment or performs the services to the patient.
2. Patient : one who is sick or injured and taking medical treatment.
3. Payer: one who protects us from risk also know as insurer.

COMMON MEDICAL BILLING :

1. INSURANCE : coverage given for any risk in current or future conditions.

2. POLICY: it is an agreement or contract between patient and payer.
3. SUBSCRIBE : someone who buys the policy from payer.
4. POLICY IDENTIFICATION NUMBER : A unique identification number given by the insurance to
identify its members and this UIN can be in numeric form or ALPHA numeric form.
5. GROUP NUMBER : A UIN given by the insurance to spefic group.
6. ENROLLMENT DATE : The date on which patient buys the policy from insurance .
7. EFFECTIVE DATE : The start date of the policy is called effective date.
8. TERMINATION DATE : The end date of the policy .
9. WAITING PERIOD : The time gap between effective and enrollement date .
10. PRE EXISTING CONDITION : If patient has an illness or disease before taking an policy (like
cancer, Diabetes)
11. WAITING PERIOD CLAUSE : It is a period of time which a patient must wait in order to get
cover the pre - existing disease by the insurance .

12. OOPS EXPENCESS {OUT OF POCKET EXPENCESS}

1. DEDUCTABILITY : {PR-1} A fixed dollar amount paid by the patient before insurance start
to pay .
2. CO INSURANCE :{PR-2} A cost percentage amount that need to paid by the patient until
the insurance .
3. CO PAY : {PR-2} A small dollar amount that patient should pay to provider in advance for
every vist .

MADHAV TRANING SERVICES 1

 CHAPTER 4

13. PREMIUM : Money paid by the member to keep policy active .

14. AUTHORIZATION : The process of getting medical services authorizes from the insurance .

TYPES OF AUTHORIZATION

1.PRIOR : Before given high dollar service to the patient provider has to take permissions
from the insurance .
2. RETRO : If provider miss to take prior authorization from the insurance but still insurance
will give a chance to take the permission from the insurance (After giving the services).
OR
After performing high dollar service to the Patient .Provider need to take permission from
the insurance.
3.REFFERAL : This authorization is given by the primary care Physician (PCP) when a patient is
reffered .
OR
REFFERAL AUTHORIZATION NUMBER (RAN)
The specialist must use RAN on his claims while billing for his services.
NOTE : Prior & Retro authorization will be given by the insurance & Refferal authorization
was given by PCP.

TFL
*. MEDICARE : TFL 365 days from DOS.
*.MEDICAID : TFL 60 days from DOS.
*.UNITED HEALTH CARE (UNC) : TFL 90 days from DOS.
*. AETNA : TFL 120 days from DOS.
*. CIGNA : TFL 120 days from DOS.
*. BLUE CROSS BLUE SHIELD (BCBS) : TFL 180 DAYS from DOS.

DOD
* MEDICARE : 120 days from DOD.
*MEDICAID : NO APPEAL.
*UHC : 180 days from DOD. *AETNA
: 180days from DOD.
*CIGNA : 180days from DOD.
*BCBS : 180days from DOD

MADHAV TRANING SERVICES 2

 CHAPTER 4

20. BILLING ADDRESS : The address where payment have to be recived.

21. PHYSICAL ADDRESS : The facility where services are rendered.

22.BENEFITS PENALITY : When a provider does not submit the information requested time
the insurance will charge penalty to the provider.

23. W9 FORM : It is a form used by the provider to update his information with the insurance

24.EXPLANATION OF BENEFITS (EOB): A statement of benefit which is issued by the insurance

to the provides which contains the status of the claim.

25. TYPES OF PATINET :

* NEW PATIENT : A patient who is visiting the facility fir the first time after 3 years .

* ESTABLISHED PATIENT : A patient who has visting the facility at least once in a 3
years.

* IN- PATINET : A patient who is admitted in hospital and getting treatment for more
than 24 hours .

* OUT – PATINET : A patient who is admitted in hospital and getting treatment for less
than 24 hours .

27. TYPES OF INSURANCE :

There are two types of insurance

*COMMERICAL
*FEDRAL
COMMERICAL INSURANCE :
*BCBS (TFL 180DAYS FROM DOS
AFL 180 DAYS FROM DOD
WEB PORTAL AVAILABILITY WE CAN FIND PRIOR AUTHORIZATION)

*UHC (TFL 90DAYS FROM DOS

AFL 180 DAYS FROM DOD
WEB PORTAL OPTUM )

AETNA (TFL 180DAYS FROM DOS

AFL 180 DAYS FROM DOD
WEB PORTAL AVAILABILITY )

CIGNA (TFL 180DAYS FROM DOS

AFL 180 DAYS FROM DOD

MADHAV TRANING SERVICES 3

 CHAPTER 4

WEB PORTAL NAVINET)

HUMANA (TFL 180DAYS FROM DOS

AFL 365 DAYS FROM DOD
WEB PORTAL AVAILABILITY)

*FEDERAL INSURANCES :

MEDICARE (TFL 360 DAYS FROM DOS

AFL 120 DAYS FROM DOD
WEB PORTAL CONNEX)

MEDICAID (TFL 60DAYS FROM DOS

AFL NO APPEAL)

28.ELIGIBILITY CRITERIA FOR MEDICARE:

*Age should be more than 65 years

*Permanenty disabled for more than 2 years.

*Individual should suffer with “ESRD” (End stage of renal diseases)

29.MEDICARE PARTS :

MADHAV TRANING SERVICES 4

 CHAPTER 4

30. MEDICARE ADVANTAGE PLAN :

MEDICARE ORGANISATION (MCO)

They are created four plans

*HMO (HEALTH MAINTENACE ORGANISATION )

*POP (POINT OF SERVICE)

*EPO (EXCLUSIVE PROVIDER ORGANISATION)

*PPO (PREFERRED PROVIDER ORGANISATION)

31.MEDICARE SUPPLEMENTARY PLAN :

It covers only Medicare PART A , PART B & PART D left balances (PATINET RESPONSIBILITIES).

32.MEDICARE CROSS OVER :

Medicare: itself will send claim forms EOB & ERA to secondary insurance.

MADHAV TRANING SERVICES 5

 CHAPTER 4

33. MEDICAID :

It is federal government insurance but runs by the state government .

ELIGIBILITY CRITERIA :

*Patient should be below poverty (BPL)

*Pregnancy women

*New born baby till 2 years Medicaid will pay

It Is a free of cost plan we cannot bill to patient for any reason in Medicaid .

34.MEDICAID SPENDUM :

The excess income that patient has to pay to the provider.

35.CHAMP US:

(CIVILIAN HEALTH AND MEDICAL PROGRAM FOR UNIFORM SERVICES)

*This is for only on duty services persons

CHAMP US has now changed to Tricare

*Armed forces

*FBI

*NAVY

*AIR FORCE

35.CHAMP VA:

(CIVILIAN HEALTH AND MEDICAL PROGRAM FOR VETERNAL AFFAIRS)

*This is for retired or disabled persons

*Armed forces

*FBI

MADHAV TRANING SERVICES 6

 CHAPTER 4

*NAVY

*AIR FORCE

39.GENERAL :

*Tax id

*NPI (NATIONAL PROVIDER IDENTIFICATION)

*SSN (SOCIAL SECURITY NUMBER)

*BA : BILLING AMOUNT

*PA : PAID AMOUNT

*AA : ALLOWED AMOUNT

*PTR : PATIENT RESPONSIBILITY

*BB : BALANCE BILL

*CO : CONTRACTUAL OBLIGATION.

40. CPT: (CURRENT PROCEDURE TERMINOLOGY)

It has 6types of CPT codes

ICD-10 run by AMERICAN MEDICAL AMENDMENT ACT)

41.CPT CODE RANGE :

MADHAV TRANING SERVICES 7

 CHAPTER 4

42. DX CODE :

*Its givens complete description to the CPT code (3-15digits)

* no ICD number.

43. MODIFIERS :

* It gives briefly explanation of DX codes

* RT –right side

* LT – left side

*24 - Unrelated post operative E/M

*25 – same day E/M

*58 – unrelated post operative minor surgery

*59 – same day minor surgery

*76 – Same day ,Same services, same provider

*77 – same day , same services, but different provider

*26 – Professional component

*TC - Technical component

44. KEY POINTS :

*MEDICARE :

1. TFL 365 DAYS

2. AFL 120 DAYS

MADHAV TRANING SERVICES 8

 CHAPTER 4

3. MEDICARE NEVER ACCEPTS PAPER

4. WE CANNOTSEND CORRECTED CLAIM TO MEDICARE

5. MEDICARE WILL NOT ACCEPT CLAIM FOR REPROCESS 6. MEDICARE

WILL NOT MAKE ANY CONTRACT WITH PROVIDERS.

*MEDICAID :

1. MEDICAID IS ALWAYS A LAST RESORT PLAN

2. WE CAN’T BILL TO PATIENT FOR MEDICAID HOLDERS.

PLACE OF SERVICES :

11 – OFFICE VISIT

12 – HOME HEALTH

21 – IN PATIENT HOSPITILIZATION

22 – OUT PATIENT

23 – EMERGENCY SERVICES

24 – AMBULATORY SURGICAL CENTER

31 – SKILLED NURSING FACILITY

34 – HOSPICE

02 – TELE HEALTH 10

– TELE HEALTH

MADHAV TRANING SERVICES 9

MADHAV CONSULTANCY & TRAINING SERVICES

MADHAV TRANING SERVICES 10

CHAPTER 5
 CHAPTER 5

What is revenue cycle management

(RCM)?
ARTICLE
Revenue cycle management (RCM) is the process healthcare organizations
use to manage financial operations related to billing and collecting
revenue for medical services. RCM begins when a patient schedules an
appointment and ends when the account balance is resolved through
reconciliation of insurance payments, contractual adjustments, write offs,
or patient payments.

RCM helps strengthen revenue by minimizing claim denials, reducing days

in accounts receivable, and increasing collections. As a result, healthcare
providers receive correct and timely payments and optimize financial
performance. Effective RCM also can help healthcare organizations comply
with regulatory requirements and improve patient satisfaction.

Steps for an effective revenue cycle include:

• Appointment scheduling: Determining the need for services, along
with collecting patient name, contact information, and insurance
coverage details
• Registration: Completing patient intake, including insurance
verification, front-desk collections, and collecting patient
demographics
• Charge capture for services: Assigning medical procedure and
diagnosis codes for the encounter
• Billing: Creating clean claims to receive reimbursement from
insurers and provide bills for patients
• Denial management: Regularly reviewing denial reason codes to
determine why a claim was denied and making corrections to
prevent denials in the future
• Accounts receivable (A/R) follow-up: Identifying and following up
on unpaid charges

There are a variety of tasks within each step and possible variations, as well.
For instance, some patient services may require prior authorization, which
usually applies to surgical procedures or other high-cost ancillary services
where insurance payers require the provider to obtain authorization prior
to performing the service.

What is the overall goal of RCM?

The overall goal of RCM is to increase and ensure accurate revenue
throughout the various processes of the cycle by identifying points of

MADHAV TRANING SERVICES 1

 CHAPTER 5

deficiency and then improving or eliminating those deficiencies. There are

additional benefits to efficiently managing your revenue cycle, such as
providing a structured, active approach to finding and addressing
potential compliance issues like fraud, waste, and abuse. For example, a
practice may discover that a provider is ordering unnecessary tests and
procedures, and the practice can then address that issue to ensure the
organization is complying with applicable rules.

Why healthcare RCM is important

Whether performed in-house or by an RCM services provider, RCM is
important because of its essential role in the day-to-day operations of
healthcare organizations. Without effective RCM, practices and facilities
are likely to lose reimbursement, which could put the entire organization
at risk. That reality translates to RCM processes having a significant impact
on the overall functioning of the healthcare industry.

Benefits of healthcare RCM:

• RCM closes the gap between the patient accounts side and clinical
side of healthcare. For instance, RCM links demographic data
(patient’s name, insurance provider, and other personal information)
with the treatment a patient receives.
• A well-designed and proper RCM system streamlines the billing and
collection cycles by accurately preregistering, making appointments
for, and scheduling patients; collecting existing balances; processing
payments; and questioning insurers when they deny claims.
• The healthcare team (including providers, managers, and specialists
in billing, coding, and preauthorization) communicates using
accounting systems and electronic health records (EHRs). Using
EHRs becomes easier with the help of RCM software or systems. This
streamlining improves the turnaround time associated with offering
a service and receiving payment for it, along with reducing
administrative overhead costs.
• RCM systems allow healthcare staff to enter all the information
required for claims processing, which helps prevent the need to
revise or resubmit claims. Reducing denied claims saves providers
time and money.
• RCM improves the patient care process, creating a better experience
for patients. For example, through insurance eligibility verification,
patients will know of any balance or financial expectations from the
beginning.
• Accurate billing and coding, as well as understanding the reason for
denials, help improve the patient experience through appropriate
charging, which leads to fewer denials. This accuracy leads to less
stress for the patient and healthcare provider.

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 CHAPTER 5

• RCM systems enable patients to pay their bills online, and healthcare
providers can use RCM systems for preserving and managing
patients’ billing records.
• RCM depends on documentation to support the medical necessity
behind the charge. Patient safety is improved because the correct
documentation leads to better overall quality of care for the patient.
Many clinicians review the patient’s chart to ensure clear
documentation, which provides a better overall picture of the
patient problem.
• RCM systems simplify reporting and analyzing data where necessary
to verify that the revenue cycle is working and performing well
within the organization.

Challenges associated with healthcare RCM

Some factors that contribute to the complexity of the revenue cycle in
healthcare relate to coding, billing, compliance, credentialing, data
analytics, and incorporating paper charts with EHRs.

RCM challenge 1: Coding precisely and billing accurately

For smooth cash flow, healthcare organizations must have precise medical
coding and accurate billing. These are separate processes, but both are
crucial to receiving payment for services performed. Medical coding
involves extracting billable information from the medical record and
clinical documentation, while medical billing uses those codes to create
insurance claims and bills for patients.

The coding and billing processes must be effective and carried out with
extreme caution, owing to the complexity involved. Errors and improper
knowledge result in leaking revenue. Denials resulting from medical
coding errors equate to lost time and lost revenue because additional
office staff time is needed to correct and resubmit follow-up claims. Also
consider the added costs for items such as postage for mailed claims,
paper, and envelopes.

The coding and billing process in healthcare can differ from organization
to organization. Some practices use one staff member as the biller and the
coder. Other practices have billing separate from coding. Outsourcing
medical coding and billing services to a trusted company is another option
for ensuring that providers have well-qualified specialists working to
obtain accurate payment. In any case, the coder researches and
determines which medical codes are appropriate to assign after reviewing
the documentation. The relationship between medical records
documentation and billing is an essential one. To support reporting the
most accurate ICD-10-CM, CPT®, and HCPCS Level II codes, documentation

MADHAV TRANING SERVICES 3

 CHAPTER 5

should be clear, precise, and thorough. When reviewing documentation,

coders should ask themselves, “Does the documentation support the
coding?” Once the codes are assigned, the biller will then perform charge
entry and bill the charges to the payer. Charge entry includes ensuring
that a patient’s correct insurance and demographic information is entered
into the billing system. The coder also verifies that the assigned procedure
and diagnosis codes correspond to the correct physician on the date of
service.

Both medical coding and billing require specialized knowledge of coding

guidelines, payer preferences, and more, and the rules change frequently.
Organizations should administer assessment tests for medical coders and
billers prior to their hire, and may conduct drug screenings to ensure that
staff members do not perform duties under the influence. Organizations
also should provide their coders and billers with training sessions to keep
knowledge and processes up to date.

RCM challenge 2: Meeting compliance standards

Healthcare compliance is the name for tasks performed to prevent fraud,

waste, or abuse within a healthcare entity. For RCM, compliance comes
into play in multiple areas. Patients’ personal information needs to be well
protected. Safeguarding the privacy and confidentiality of their health
information must be a top priority. Under the Health Insurance Portability
and Accountability Act (HIPAA) of 1996, organizations are legally
responsible for protecting the privacy and security of certain health
information. Patient medical records should not be open for disclosure
under most circumstances due to potential breaches. This provides
patients the security that their medical records and personal information
are safeguarded and protected from misuse.

Healthcare RCM also must meet additional compliance requirements,

such as having a high standard for coding accuracy, conducting relevant
facility audits for compliance, following rules for filing medical claims
electronically, and maintaining workstations that comply with HIPAA
requirements. Failing could cost the practice significant fines, potentially
exceeding $1 million, if government auditors discover deficiencies in an
organization’s compliance practices.

RCM challenge 3: Credentialing providers

Provider credentialing is the process where the provider connects with the
payer for approval following a set of standard steps. Examples of steps
include confirming the provider’s information (education, board
certification, etc.) is correct and submitting required documentation.
Credentialing is a vital step in any revenue cycle. If the provider is not

MADHAV TRANING SERVICES 4

 CHAPTER 5

credentialed, the payers will delay or reject reimbursement. Medical

practices should have a credentialing specialist to handle these tasks.

RCM challenge 4: Applying data analytics

Data analytics is the process of reviewing reports (for denials,

appointments, charges billed, reimbursement collections, etc.) and other
documentation and looking for trends within the revenue cycle. This
includes noting trends such as errors, missed billing opportunities, and
determining whether revenue is up or down. Data analytics can tell a story
about processes, such as if a process is being followed or is broken. This
analysis makes a huge impact within the healthcare industry. Identifying
and correcting direct behaviors that are negatively impacting revenue can
improve both accuracy and efficiency.

RCM challenge 5: Incorporating paper charts

Paper charts are challenging for RCM because they are separate from EHR.
This separation complicates the patient care process . Because paper chart
documentation is not included in the EHRs, only providers within the
practice that created the charts typically view them. If other providers do
not have access to this additional information, there may be diminished
quality of care, as well as incomplete information for coders, auditors, and
others focused on ensuring claims accurately reflect patient conditions
and encounters.

How to improve revenue cycle processes in a

clinic or physician practice
Clinics and physician practices can improve revenue cycle processes by
checking each step of the revenue cycle to determine what is working well
and where there is room for improvement. Using the data analytics
mentioned above offers RCM managers organization-specific facts to help
support decisions about any changes. Below are some top areas to watch
to improve revenue cycle processes.

First, successful RCM hinges on remembering that each step of the cycle is
linked. A problem in one area can ripple out to create problems in other
steps. Including a qualified RCM manager or director on the staff improves
efficiency. This valuable team member is capable of communicating
effectively with clinicians and other providers, has expert medical billing
knowledge, and maintains an organized office. This person also must be
able to answer RCM-related questions and know how to research answers
effectively. In addition, the revenue cycle manager or director unites the
front- and back-end operations. Front-end processes involve patient
contact, such as registration, eligibility, precertification, and direct patient

MADHAV TRANING SERVICES 5

 CHAPTER 5

care. Back-end patient accounts processes involve administrative-type

responsibilities, such as working on claims, denials, medical billing, and
collections.

Here are some examples of how handling front-end processes properly

can lead to smoother back-end processes:

• Medical billing begins with scheduling the appointment and

registration because if patient demographics and details, such as
name, address, gender, spouse information, and whether a visit is
due to a work-related injury, are incorrect, the medical claim denial
has already been triggered. Insurers will not accept claims with
incomplete or inaccurate patient information.
• Verifying patient eligibility prior to each visit will ward off denials.
This step confirms that the patient is covered by the payer and plan
the patient has specified.
• Handling prior authorization (also called precertification or
preauthorization) carefully will help revenue management. Practices
cannot afford to lose revenue due to lack of prior authorization,
which refers to a health plan requirement for patients to obtain
approval for certain healthcare services or medications prior to
receiving care.
• Involving providers when necessary may increase the likelihood that
a payer will reimburse for a service. For example, an ordering
provider may need to join a peer-to-peer review with a provider who
works for the payer. These reviews focus on why a patient needs a
service or medication so the payer understands the provider’s
request for prior authorization. The business team must
communicate with the clinical team to coordinate this, keeping in
mind that a provider’s time is valuable, but also conveying that if the
peer-to-peer call is missed, the authorization is gone.
• Communication and coordination between staff members who
document clinical records and those who handle patient accounts
can prevent problems caused by conflicting information.

Additional steps that clinics and practices can take to improve RCM
include the following:

• Stay abreast of relevant guidelines and changes, including medical

code updates. Using invalid codes or reporting codes incorrectly
leads to issues with claims and delays in payment.
• Have edits in place for charges and coding. Edits will catch incorrect
reporting and missing items such as modifiers, National Correct
Coding Initiative (NCCI) edits, and more, to assist with smoother
claims processing and payment.
• Have a compliance liaison who audits charges to ensure accurate
billing.

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 CHAPTER 5

• Work denials not only in a timely manner (within the timeframe

required by the payer), but strategically. Assess for similar denials,
and work on them as a group to bring the revenue back in as
efficiently and quickly as possible.
• Allow technology to help streamline processes when it’s beneficial to
do so. The next section offers more examples of how technology can
help.

Why should healthcare facilities use RCM

software solutions?
Medical RCM software is essential for medical practices and facilities to
streamline tasks. The software can help with many things, from scheduling
appointments correctly to ensuring accurate medical billing and coding so
that insurers can process claims and practices can collect payments on
time. Electronic software can handle all aspects of the patient chart faster,
more efficiently, and more accurately than manually performing the
necessary tasks. Software decreases the need for manpower, allowing the
team to focus on higher-priority tasks.

Technology helps drive healthcare RCM to the next level of effectiveness.

The risk of error increases when claims are processed manually or while
using outdated claims software and related technology. Implementing the
most current RCM technology will help with the following:

• Reducing phone calls and hold times

• Standardizing eligibility and prior authorization via online payer
systems; most eligibility issues can be eliminated while using
technology aimed at verifying patient plans, increasing accuracy in
billing “clean” claims, improving follow-up, and effectively resolving
potential denials
• Keeping the revenue team up-to-date on payer policies and their
respective billing and reimbursement criteria
• Providing training and updates regarding government regulations
that may present challenges for practices and others facing a money
crunch
• Collecting patient payments using online patient portal systems to
eliminate phone calls and the need to generate multiple statements,
to assist with posting payments, and to reduce turnaround time for
payments

What to look for when selecting an RCM

system

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 CHAPTER 5

When healthcare organizations are selecting an RCM system, one of the

main elements to confirm is that the system has comprehensive and
customizable applications, meaning it is well-rounded and gives each
organization the ability to make the system work for it. System
applications to look for include patient registration, collections, and easy
charting for providers.

RCM system technology and security must be advanced and savvy, which
reduces the possibility of exposed or compromised information. Newer
systems can find the most recent patient address for billing past due
invoices. These RCM systems also can verify a patient’s insurance eligibility.
Previous systems with fewer capabilities led to office staff having to make
more phone calls, resulting in less overall efficiency. Up-to-date RCM
systems support another important consideration: Healthcare providers
and the RCM staff need to have confidence that the RCM system in place
is reliable, relatively simple to navigate, and provides transparency.
Systems that stall, delay, or are cumbersome to use lose the trust of the
RCM staff and providers.

A key consideration for RCM system selection is finding one that provides
personalized customer service, such as on-site training and user
certification. RCM system users may find in-person support superior to
training videos, which run the risk of viewers losing interest and not fully
digesting the instruction. Other RCM system criteria should include the
ability to run reports smoothly to check data points, which may include
“missing charge” reports (which identify visits that do not have a charge),
copay collections, and daily appointment lists.

How to know if your RCM is performing well

Data is the key to assessing your RCM, whether you keep tasks in-house or
outsource them to an RCM service. Analyzing data that shows financial
and performance benchmarks proves where the RCM is achieving its goals
and where to make improvements.

Important healthcare RCM financial and performance benchmarks

include:

• Point-of-service (POS) cash collections: This data reports

copayment collection. Healthcare practices and facilities are in
contract with payers, and copayment revenue is part of that
contract.
• Days in accounts receivable: This component tracks revenue
collection processes, including the length of time it takes to collect
payment for each invoice.

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 CHAPTER 5

• Days in total discharged not billed: This item reports when a

patient has been discharged from a hospital and the dates of service
not yet billed.
• Clean claim rate: This benchmark measures “clean billing.” It tracks
claim denials and related errors, and it assists with forming an action
plan to fix problems when necessary.
• Bad debt: This data reflects how much “bad” debt (debt that is
unlikely to be paid back) is owed to the practice or facility. It also
indicates whether the collections department is performing
effectively to obtain outstanding patient balances.

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CHAPTER 6
 CHAPTER 6

No Claim On File

On call analysis and Scenario :

• When getting the status as no claim on file, always check the
clearinghouse whether the claim was sent to insurance or it is rejected, if it
is rejected then work as per the rejection.
• There could be more than one CPTs billed on the same DOS or two
DOS could be billed in a single claim form, so always open the claim form
and provide the DOS range and total billed amount as mentioned in the
claim form.
• POTF stands for Proof of timely filing.
• You can consider the below proof as POTF if these occurred within
TFL.
o An initial filed claim to the same insurance which is not
received by the payer.
o Initially rejected claims.
o Initial billing to any other payer.

No claim on file
↓
May I have policy effective and termed date?
↓
Check DOS lies between effective and termed date
↙ ↘
Yes No
↓ ↓
May I have the TFL? ← ← Is there any other policy
↓ ↖ active for the patient on DOS?
Check DOS lies within TFL ↖ ↙ ↘
↙ ↘ ↖ Yes No
Yes No ↖ ↓ ↓
↓ ↓ ← May I have May I get
May I have claim Can we fax or Policy ID, Policy call ref#?
mailing address, mail the claim effective and
Payer ID and Fax#? along with POTF? termed Date?
↓ ↖ ↙ ↘
May I get call ref#? ↖ ← No Yes
↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?

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 CHAPTER 6

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the patient policy is active on DOS and DOS lies within TFL and
the payer ID & mailing address are the same as the system details then you
can resubmit the claim.
• If the payer ID provided by the rep is different than the payer ID
mentioned in the system then search for the correct payer ID, update the
correct plan code, and resubmit the claim.
• If the correct payer ID is not available then Fax the claim if the Fax#
is provided by the rep or else drop the claim through paper.
• Always give priority to the submission of a claim via payer id or Fax#
since sending a claim via mail takes a longer time.
• If the patient policy is active on DOS and DOS has crossed the TFL
and the rep confirms that you cannot fax or mail the claim along with POTF
then resubmit the claim. Once TFL denial receives then you can send an
appeal with POTF.
• If the patient policy is active on DOS and DOS has crossed the TFL
and the rep confirms that you can fax or mail the claim along with POTF
then fax/mail the claim along with POTF. (Sometimes, the client wants to
resubmit the claim instead of mailing or faxing the claim with POTF and
waiting for TFL denial, and then sending the appeal. So, work as per the
instructions.)
• If there is no POTF and the claim was billed after TFL was crossed
then the claim needs to be written off.
• If the patient's policy was inactive on DOS and the rep provided the
details of another active policy of the patient then before resubmitting the
claim update the correct policy ID given by the rep.
• If the patient's policy was inactive on DOS and no other active policy
is available then release the claim to the patient if there is no other insurance
available in the system.
• If the other insurance is available in the system then check the
eligibility for that insurance and if the policy is active on DOS then make
that insurance as primary insurance and submit the claim.

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 CHAPTER 6

Claim in Process
Scenario Occurrences:

• This scenario occurs when you call the insurance within the TAT
(Turn Around Time) or if the insurance needs additional information from
the provider or patient.
• TAT - It is the amount of time taken by the insurance to complete the
claim processing.
• TAT should always be calculated from the received date of a claim.

On Call Scenario:
Claim in process
↓
When did you receive the claim?
↓
What is the normal processing
time or TAT?
↓
Calculate TAT from received
date and check if is it within the TAT?
↙ ↘
Yes No
↓ ↓
May I get Claim# May I have the
& Call ref#? reason for delay?
↙ ↓ ↘⟶⟶⟶
↙ ↓ ↓
Any Information Information requested Other Reasons
or documents from patient (Backlog)
requested from ↓ ↓
provider Have you sent May I get
↓ letter to patient? Claim# &
What documents/info ↙ ↘ Call ref#?
requested? Yes No
↓ ↓ ↓
May I have the When did May I get
address or Fax# to you send Claim# &
send the document/info? the letter? Call ref#?
↓ ↓
May I get Claim# May I get

& Call ref#? Claim# &

Call ref#?

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 CHAPTER 6

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is within the TAT then you should set follow-up for the
remaining days.
• If the claim received date has crossed the TAT and the delayed reason
provided as additional information requested from the provider then you can
send the document to insurance if it is available and you have the authority
to send it or else assign the claim to the correct department to send it.
• If the requested document is not available then take action as per the
update. This document needs to get from the client.
• If the claim received date has crossed the TAT and the delayed reason
provided as additional information requested from the patient and a letter is
sent to the patient and the date when a letter was sent to the patient has not
crossed one month then do not bill the claim to the patient and at least wait
for a month before releasing it to the patient since it takes time to receive the
letter to the patient and update the information with insurance. So, set the
follow-up of 1 month from the letter sent date.
• One month of waiting time is given to the patient to update
information but always follow your client's instructions whether we need to
wait for one month or not.
• If the date when a letter was sent to the patient has crossed one month
then release the claim to the patient.
• If the claim received date has crossed the TAT and the delayed reason
is provided as additional information requested from the patient and the
letter is not sent to the patient then you can release the claim to the patient.
• If the claim received date has crossed the TAT and the delayed reason
is provided as backlog then you can set the follow-up for more days.
• When getting status as the claim is pending due to litigation then it
takes a longer time for resolution since it is based on the court’s decision.

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 CHAPTER 6

Approved to Pay
Scenario Occurrences:
• This scenario occurs when the claim is finalized to pay but the
payment is not released yet.

On Call Scenario:
Approved to pay
↓
What is the processed date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible, or Co-payment)?
↓
Verify sum of PA and Patient Responsibility(PTR) equals to AA,
if not then probe the rep and get the correct information

↓
When can we expect the payment?
↓
May I have the claim# & Call ref#

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is approved to pay and the rep has provided the expected
days for payment then you should set the follow-up for that much time.
• Sometimes, when insurance is located in IL state, we come across this
scenario while working on a few insurances where insurances usually take
50-60 weeks to release the payment.

Claim Paid
Scenario Occurrences:

• This scenario occurs when the claim is paid but payment information is not received
yet or posted.

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 CHAPTER 6

On Call Scenario:
Claim Paid
↓
What is the processed & paid date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible or Co-payment)?

↓
Verify sum of PA and Patient Responsibility(PTR) equals to AA,
if not then probe the rep and get the correct information

↓
Was payment done through Check or EFT/Credit Card?
↙ ↘
Check EFT/Credit Card
↓ ↓
What is the check#? What is the Transaction ID?
↓ ↓
Was it Single check or Bulk check#? Was it single payment or Bulk payment?
↙ ↘ ↙ ↘
Single check Bulk Check Single payment Bulk payment
↘ ↓ ↘ ↓
↘ What is the Bulk Amount? ↘ What is the Bulk Payment Amount?
↘ ↙ ↘ ↙
May I have the check mailing address? Is payment cleared?

↓ ↙ ↓ ↘
Validate address provided by rep with Yes Not Provided No
the address available in box# 32 and 33 ↓ ↓ ↓
↙ ↘ ↓ ↓ ↓
Correct Incorrect ↓ ↓ ↓
↓ ↘ May I have the ↓ EFT/Credit card
Is the check cashed? ↘ encashment date ↓ payment takes 2-3
↙ ↘ ↘ → → → ↘ ↓ ↙ days for clearance
Yes No ↘ Provide correct Could you please but not more than
↓ ↓ Rep does not check mailing fax the EOB? If 7 days. So, if the paid
May I have the ↓ have encashment address to rep & not then mail it or date has crossed 7 days
encashment ↓ date information? ask to reissue new provide the source then it means payment
date? ↓ ↓ check to get the EOB might get cancelled. So,
↓ ↓ Could you please ↓ ↘ verify same with rep &
Could you please Is paid date fax the EOB? If rep agrees? May I have ask rep to reissue new
fax the EOB? If crossed 45 days? not then mail it ↙ ↘ the Claim# & payment
Not then mail it ↙↘ or provide the source Yes No Call ref ↓
or provide the ↙ ↘ to get the EOB ↓ ↘ rep agrees?

source to get the ↙ ↘ ↘ What is the TAT? What is the ↙ ↘

EOB Yes No ↘ ↓ reason? Yes No
↓ ↓ ↘ → May I have ↓ ↓ ↓
May I have the Could you please How many days the claim# & Can I get the fax# What is What is the
claim# & Call run check tracker will it take to Call ref#? or mailing address TAT? reason?
ref#? to get the current clear the check? to send W9 form ↓ ↓
status of the check? ↓ to update the correct ↓ Could you
↓ Could you please address? May I have please fax the
Rep agrees fax the EOB? If ↓ the Claim# & the EOB? If
↙ ↘ not then mail it May I have the Call ref#? not then mail
Yes No or provide the source Claim# & Call ref#? it or provide
↓ ↓ to get the EOB the source to
What is the TAT? ↓ ↓ the EOB
↓ ↓ May I have the ↓
Could you please fax the EOB? Claim# & Call ref#? May I have
If not then mail it or provide the the claim# &
source to get the EOB call ref#?
↓
May I have the Claim#
& Call ref#?

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 CHAPTER 6

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is paid through a check on the correct address and the
check is encashed and you receive the EOB then you can note the account
and send the EOB it for posting.
• If the claim is paid through a check on the correct address and the
check is encashed and you do not receive the EOB then you can note the
account.
• If the claim is paid through a check on the correct address and the
check is not encashed and paid date has crossed 45 days and the rep agrees
to run the check tracer to get the status of the check then you can set the
follow-up for TAT provided by the rep.
• If the claim is paid through a check on the correct address and check
is not encashed and paid date has crossed 45 days and the rep denies to run
the check tracer then you can note the account.
• If the claim is paid through a check on the correct address and check
is not encashed and paid date has not crossed 45 days then you can set
follow-up for the days that will take to clear to check.
• If the claim is paid through a check on the correct address and check
encashment detail is not available and you receive the EOB then you can
note the account and send the EOB for posting.
• If the claim is paid through a check on the correct address and check
encashment detail is not available and you do not receive the EOB then you
can note the account.
• If the claim is paid through a check on an incorrect address and the
rep agrees to reissue a new check then you can set the follow-up for the
TAT provided by the rep.
• If the claim is paid through a check on an incorrect address and the
rep denies to reissue a new check then you can send a W9 form to insurance
if available.
• Most of the time rep denies to reissue a new check when they do not
find the correct mailing address. So, we need to send a W9 form to update
the mailing address.
• If the W9 form is not available then you can take the action as per the
update. A W9 form needs to be asked to the client.
• If the claim is paid through EFT or Credit Card and the payment is
cleared and you receive the EOB then you can note the account and send the
EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment is
cleared and you do not receive the EOB then you can note the account.

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 CHAPTER 6

• If the claim is paid through EFT or Credit Card and the payment
clearance information is not available and you receive the EOB then you can
note the account and send the EOB for posting.
• If the claim is paid through EFT or Credit Card and the payment
clearance information is not available and you do not receive the EOB then
you can note the account.
• If the claim is paid through EFT or Credit Card and the payment is
not cleared and paid date has crossed 7 days and the rep agrees to reissue a
new check then you can set the follow-up for the TAT provided by the rep.
• If the claim is paid through EFT or Credit Card and the payment is
not cleared and paid date has crossed 7 days and the rep denies to reissue a
new check then you can note the account.

Claim paid and applied towards offset

Scenario Occurrences:
• This scenario occurs when insurance already paid an additional
amount to the provider in the past and to cover that amount, they process
and paid the current claim but do not release any payment. Instead, they ask
to consider it from an additional amount paid in the past.

On Call Scenario:
Claim paid & applied towards offset
↓
May I get processed and paid date?
↓
What are the allowed amount, paid amount and
patient responsibility (Coins, Deductible or Co-payment)?

↓
May I know the reason, why is it applied towards offset?
↓
May I know to which patient is it applied towards offset?
↓
May I know the patient account#, DOS & CPT?
↓
Could you please fax the EOB? if not then mail it
or provide the source to get the EOB?
↓
May I know the claim# & call ref#?

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Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If you receive the EOB then you can note the account and send the
EOB for posting.
• If you do not receive the EOB then you can note the account.

1: Deductible Amount
Scenario Occurrences:

• Deductible: It is a fixed amount that the policyholder needs to pay

before an insurance company starts making payment for the treatment.
• For example, if a policyholder has a deductible of $2,000.00 and
he/she undergoes a treatment that costs $1,500.00. So, when this claim is
billed to insurance, it will apply toward the deductible and the policyholder
will be paying this amount.
• If the policyholder undergoes for second treatment that costs
$1,200.00 then this time insurance will apply $500.00 towards the patient
deductible and process the remaining $700.00. When processing $700.00, it
can also include patient responsibility as coinsurance or copayment based on
the policy contract. The policyholder will be responsible for paying the
deductible amount of $500.00.
• The deductible clause can be in terms of visit or dollar amount.
• If it is based on a visit then the policyholder will be responsible for
full payment of the treatment cost until it reaches the allowed visit.

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 CHAPTER 6

On Call Scenario:

Claim applied toward Deductible

↓
May I have the processed date?
↓
What is the Allowed Amount(AA)?
↓
How much is the total deductible limit on the policy?
↓
How much has patient met including this claim?
↙ ↘
If patient has met the deductible including this claim/ If patient has already met the
Patient has not met the deductible including this claim deductible excluding this claim
↓ ↓
Could you please fax the EOB? If not then mail it Could you please send the claim
or provide the source to get the EOB? back for reprocessing since
↓ patient has already met his
May I have the claim# & call ref#? deductible excluding this claim?
↓
What is the Turn around
time(TAT) for reprocessing?
↓
May I have the claim#
& call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• Once you receive the EOB through fax then note the account and
send the EOB for posting and if EOB is sent to the mailing address then note
the account.
• If the claim is sent back for reprocessing then you can set the follow-
up for the TAT provided by the rep.
• Once the deductible is posted the claim can be billed to a secondary
or consecutive payer. Before billing the claim to a secondary or consecutive
payer, need to verify the eligibility of the patient for a secondary or
consecutive payer.
• To verify the eligibility of secondary or consecutive payer, check the
payer website if access is available or else call the insurance.
• If the patient policy is active for secondary or consecutive payers on
DOS then rebill the claim.

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 CHAPTER 6

• If no other payer is active or available on DOS then release the claim

to the patient once the deductible is posted.
• When the claim is applied towards deductible by the Medicare payer
then Medicare always forwards the claim to the consecutive payer. In this
case, if the processed date crossed 30 days and we have not received any
response from consecutive payers then call the insurance and verify the
status.
• Sometimes the claim is processed as out of network then there is no
need to take the adjustment and the full amount can be billed to the
secondary or consecutive payer. If there is no other payer available then bill
the amount to the patient.

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 CHAPTER 7

31: Patient cannot be identified as our insured

Denial Occurrence:

• This denial occurs when an incorrect patient name, Date of birth, or

Gender is billed.

On Call Scenario:
Patient cannot be identified
↓
Could you please search the patient with
Name, DOB or Social Security#?
↙ ↘
If rep finds the patient If rep unable to find patient
↓ ↓
May I have the correct policy ID? May I get call ref#?
↓
Could you please check if claim
is available for the DOS with correct
member ID?
↙ ↘
Yes No
↓ ↘
Follow AR Scenario May I have the effective and
Tool as per the claim status termed date of the policy?
↓
Check if DOS lies between
effective and termed date
↙ ↘
No Yes
↓ ↓
May I get call ref#? May I have the Timely
filing limit(TFL)?
↓
Check DOS lies within TFL
↙ ↘
Yes No
↙ ↓
May I have claim Can we fax or mail the
mailing address, ← claim along with POTF?
Payer ID and Fax#? ↖ ↙ ↘
↓ ← No Yes
May I get call ref#? ↓
May I have Fax#
or Mailing address
to send claim along
with POTF?
↓
May I get call ref#?

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Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the rep is unable to find the patient or when this denial occurs then
the claim can be released to the patient if no other active insurance is
available.
• Before releasing the claim to the patient, check the web portal of the
insurance if access is available to verify the patient's information.
• Always check previous DOS, if payment from any other insurance
was received or not. If yes, then check the eligibility for that payer for DOS
and resubmit the claim if the patient policy is active.
• If the rep is able to find the patient and claim after the Name, DOB &
SSN search then follow the AR scenario as per the status of the claim.
• If the rep is able to find the patient but not the claim and the patient's
policy is not active on DOS then the claim can be released to the patient if
there is no other active insurance available.
• If the rep is able to find the patient but not the claim and the patient
policy is active on DOS and DOS lies within TFL and the payer ID &
mailing address are the same as the system details then you can resubmit the
claim.
• If the rep is able to find the patient but not the claim and the patient
policy is active on DOS and DOS has crossed the TFL and the rep confirms
that you cannot fax or mail the claim along with POTF then resubmit the
claim. Once TFL denial receives then you can send an appeal with POTF.
• If the rep is able to find the patient but not the claim and the patient
policy is active on DOS and DOS has crossed the TFL and the rep confirms
that you can fax or mail the claim along with POTF then fax/mail the claim
along with POTF. (Sometimes, the client wants to resubmit the claim
instead of mailing or faxing the claim with POTF and waiting for TFL
denial, and then sending the appeal. So, work as per the instructions.)
• If the rep is able to find the patient but not the claim and there is no
POTF and the claim was billed after TFL was crossed then the claim needs
to be written off.
• For Medicare, it is necessary to have the correct policy ID, Name, and
DOB as mentioned in the ID card, or else it will be denied as the patient
cannot be identified. Medicare policy format has now changed from HIC to
MBI. Both have 11 characters whereas the HIC number has a suffix at the
end of the SSN and MBI has 11 characters in alpha-numeric format.

• When you received an ID denial from Medicare and you have an

MBI number but there is a patient name issue then you can search for the
correct last and first name on the web portal. Sometimes last and first names

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are replaced with each other. Also, you can try to pull the patient by adding
Jr, Sr, I, II, III, and IV in the last name.
• Never billed Medicare ID denial to supplementary plan because they
would also deny the claim stating primary insurance denied the claim, so
they will not process the claim.
• BCBS policy format has 3 characters alpha prefix and If the claim is
billed without the prefix, it will get denied for a patient not identified. These
prefixes are based on state and if you have the SSN of the patient then you
can pull the patient on the Availity web portal, this trick is not 100%
accurate but works sometimes. For example, for NM state, use YIF or XIF
followed by SSN. For the MI state, use XYL followed by SSN, etc.
Similarly, you can find the prefix details for the state you are working in and
try with SSN.

26: Expenses incurred prior to coverage/27: Expenses incurred after

coverage terminated

Denial Occurrence:

• This denial occurs when the service is performed on a date that does
not lie between the policy effective date and the policy termination date.

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 CHAPTER 7

On Call Scenario:

Claim denied as member coverage

terminated or Policy termed
↓
May I get the denial date?
↓
May I have the policy effective and termed date?
↓
Check if DOS lies between effective and termed date
↙ ↘
Yes No
↓ ↓
Could you please send the Is there any other policy
claim back for reprocessing active for patient on DOS?
since policy active on DOS? ↙ ↘
↓ Yes No
What is the TAT for ↓ ↓
reprocessing? May I have policy ID, May I have the
↓ Policy effective and claim# & call ref#?
May I get the Claim# termed date?
& Call ref#? ↓
May I have the claim#
& call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the rep sends the claim back for reprocessing then you should set
the follow-up for the TAT provided by the rep.
• If the rep finds another policy that is active on DOS then you can
update the new policy ID and resubmit the claim.
• If the policy is inactive and there is no active policy on DOS then you
can release the claim to the patient.
• Before releasing the claim to the patient, check if any other insurance
is available or not.
• When other insurance is available then check eligibility for that
insurance on the web portal if access is available and if the patient is active
for that insurance as primary then make it primary and resubmit the claim.
• Always check previous DOS, if payment from any other insurance
was received or not. If yes, then check the eligibility for that payer for DOS
and resubmit the claim if the patient policy is active.

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29: The time limit for filing has expired

Denial Occurrence:
• This denial occurs when insurance receives the claim after TFL
expired.
TFL:
• TFL stands for timely filing limit.
• A timely filing limit is a time frame set by an insurance company for
providers to submit a claim.
• TFL must be calculated from the date of service (DOS).
POTF:
• POTF stands for Proof of timely filing.
• You can consider the below proofs as POTF,
o An initial filed claim to the same insurance which is not
received by the payer.
o Initially rejected claims.
o Initial billing to any other payer.
AFL:
• AFL stands for appeal filing limit.
• ATL must be calculated from the date of denial (DOD).

On Call Scenario:

Claim denied as Past timely

filing or TFL expired
↓
May I get the denial date?
↓
When did you receive the claim?
↓
How much is the Timely filing limit?
↓
Check if the claim was received within TFL
↙ ↘
Yes No
↓ ↓
Could you please send the Check if POTF available
claim back for reprocessing ↙ ↘
since the claim was received Yes No
within TFL? ↓ ↓
↓ Can we appeal with POTF? May I have
What is the TAT for reprocessing? ↓ the claim# &
↓ What is the fax# or Mailing call ref#?
May I have the claim# & address to send an appeal? &
call ref#? What is the appeal limit?
↓
May I have the claim# &
call ref#?

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Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim was denied incorrectly and the rep send the claim back
for reprocessing then you can set the follow-up for the TAT provided by the
rep.
• If the claim was billed after TFL expired and POTF is available that
proves that we billed the claim within TFL then send an appeal to insurance.
• If the claim was billed after TFL expired and there is no POTF
available then you can adjust the claim.
• You may come across a scenario where a claim was initially billed
within TFL to different insurance and billed to current insurance after TFL
expired then you can use initial billing information as POTF and send an
appeal to insurance.
• Calculate the appeal filing limit, if it is not crossed then send the
POTF, or else write off the claim if the appeal filing limit is crossed.
• Sometimes the client wants us to send POTF even if the AFL is
crossed, so work accordingly.
• You may also come across a scenario where the claim was billed to
insurance on the last date of the TFL period but the claim was received by
insurance after the TFL expired (for example, TFL is 90 days and the claim
was billed on 90th day to insurance but the claim was received by the
insurance on 91st day or afterward). Then you can send an appeal on such
claims with POTF to receive the payment.

197: Precertification/Authorization/Notification/Pre-
treatment absent

Denial Occurrence:
• This denial occurs when authorization is not obtained for a service or
treatment that requires authorization.
• Authorization number can be found on Box# 23 on the CMS1500
form or Locator# 63 on the the UB04 form.
• Sometimes, the rep says the claim is denied as authorization is needed
because the provider is out of network. In that case, do not consider it as
Auth denial and follow the scenario of 242: Services not provided by
network/primary care providers.
• Prior Authorization/Pre-Authorization: It is a process of obtaining
authorization prior to performing the treatment.

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 CHAPTER 7

• Retro Authorization: It is a process of obtaining authorization after

performing the treatment.

On Call Scenario:

Claim denied as Authorization

Absent or Missing
↓
May I get the denial date?
↓
Check in system if Auth# is Available
↙ ↘
Yes No
↓ ↓
I have the Auth#, Can you please Check place of service billed on
reprocess the claim using this Auth#? claim is 23 (Emergency) or not
↓ ↗ ↙ ↘
Rep Agrees? ↗ Yes No
↙ ↓ ↗ ↓ ↓
Yes No ↗ ↓ Do you have Auth# on file? OR
↙ ↙ ↘ ↑ Could you please Is there any hospital claim
What is turn Need to Auth# is reprocess the claim billed on same DOS where
around time send an invalid since it is an authorization# present?
for processing? corrected emergency service (The above highlighted question
↓ claim & does not require is only applicable for
May I have the ↓ Auth#? non-hospital billing claims)
claim# & call ref#? What is ↓ ↗ ↙ ↘
the time Rep Agrees? ↗ Yes No
limit to send ↙ ↘ ↗ ↓ ↓
a corrected Yes No ↓ ↓
claim? ↓ Could you please Is it possible to
↓ What is the TAT ← ← use that Auth# and obtain Retro
May I have the for reprocessing? send claim back for Authorization#?
claim# & call ref#? ↓ reprocessing? ↙ ↘
May I have the Yes No
claim# & call ref#? ↙ ↓
What is the What is the
procedure to obtain Fax# or mailing
retro Auth#? address to send
↓ an appeal?
May I have the ↓
claim# & call How much is
ref#? the time limit?
↓
May I have the
claim# & call
ref#?

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Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the Auth# is available in the system and the rep agrees to reprocess
the claim then set the follow-up for the TAT provided by the rep.
• If the Auth# is available in the system and the rep denies to reprocess
the claim and asks to send a corrected claim then update the Auth# correctly
and submit the corrected claim by updating the correct billing code "7"
along with the claim number.
• If the Auth# is not available in the system and the service is an
emergency service and the rep agrees to reprocess the claim then set the
follow-up for the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep finds Auth# on his/her system or on the
hospital claim and agrees to reprocess the claim then set the follow-up for
the TAT provided by the rep.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep does not find Auth# on his/her system or on
the hospital claim but says that it is possible to obtain retro authorization
then follow the procedure given by the rep.
• The procedure of obtaining retro authorization involves filling out the
form and sending the requested documents. If the documents are available to
you then you can fill out the form and attach the documents and send them
to insurance.
• If the documents are not available then you can ask to client.
• If the Auth# is not available in the system and the service is not an
emergency service and the rep does not find Auth# on his/her system or on
the hospital claim and says that it is not possible to obtain retro authorization
then the claim must be written off. But, sometimes clients want to send an
appeal if nothing can be done. So work as per your client's instructions.
• Auth# can also be found on the Evicore website for the payers listed
on the website. This website provides the Auth# approved for the specific
CPT code under the specific time period.
• Few insurances advise contacting Evicore insurance to obtain Auth#.
so if you have website access then you can directly check if Auth# is
approved for the CPT or not else need to call Evicore insurance and find out
the details.

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119: Benefit Maximum for this time period or

occurrence has been reached

Denial Occurrence:

• Sometimes, there is a limit on a policy where certain services are

allowed to pay only for a limited dollar amount or number of visits in a year
or lifetime.
• When the insurance payment reaches that limit then this denial
occurs.
• For example, if a service is limited to pay $1,000.00 in a year and a
patient has already taken the same service 5 times in a year where the
insurance has already made the payment of a total of $1,000.00. Now, if the
patient goes for the same treatment again then insurance will not pay the
claim this time and it will not get denied as the maximum benefit exhausted
since the allowed dollar amount is already paid.
• For example, if a service is limited to pay for 5 times in a year and a
patient has already taken the same service 5 times in a year where the
insurance has made the payment for all the 5 times. Now, if the patient goes
for the same treatment again then insurance will not pay the claim this time
and it will not get denied as the maximum benefit exhausted since allowed
visits are already paid.

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 CHAPTER 7

On Call Scenario:

Claim denied as patient has reached

the maximum benefit allowed
↓
May I get the denial date?
↓
May I know maximum benefit reached in terms of dollar or visit?
↙ ↘
In terms of Dollar In terms of Visit
↓ ↓
How much Dollar amount How many Visit is
is allowed? allowed?
↓ ↓
How much dollar amount has How much visit has patient
patient met excluding this claim? met excluding this claim?
↓ ↓
Has patient met the allowed dollar Has patient met the allowed visit
amount excluding this claim? excluding this claim?
↙ ↘ ↙ ↘
Yes No Yes No
↓ ↓ ↓ ↓
May I have the Could you please May I have the Could you please
claim# & call ref#? send the claim back claim# & call ref#? send the claim back
for reprocessing since for reprocessing since
patient has not met the patient has not met the
the allowed dollar allowed visits
amount excluding this amount excluding this
claim? claim?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If a patient has met the allowed dollar amount or visit excluding this
claim then the claim must be billed to the secondary payer/consecutive
payer or patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
MADHAV TRAINING SERVICES 10
 CHAPTER 7

• If a patient policy is active for secondary or consecutive payers on

DOS then bill the claim.
• If no other payer is active or available on DOS then release the claim
to the patient.
• When billing a claim to secondary insurance then do not change the
payer sequence i.e. do not make secondary as primary and bill the claim or
else the primary denial reason will not be sent to secondary insurance and
the claim would be denied as need primary EOB.
• If the patient has not met the allowed dollar amount or visits
excluding this claim and the rep send the claim back for reprocessing then
set the follow-up for the TAT provided by the rep.

96: Non-Covered Charges

Denial Occurrences:
• This denial has 2 categories:
o Non-covered charges as per patient plan
o Non-covered charges as per provider contract
• Non-covered charges as per patient plan: This denial occurs for
below reasons,
o Provider is out of network
o Non covered DX or ICD-10 code under patient policy
o Non-covered CPT code under patient policy
• Non-covered charges as per provider contract: This denial occurs
when the CPT code is non-covered under the provider contract.

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 CHAPTER 7

On Call Scenario:

Claim denied as Non Covered Charges

↓
May I get the denial date?
↓
Is it non covered as per patient plan or provider contract ?
↙ ↘
Non covered as per patient plan Non covered as per provider contract
↓ ↓
What is the reason for non covered? What is the reason for non covered?
↙ ↓ ↘ ↙ ↘
Provider is DX or ICD-10 other CPT non covered under Other reasons
out of network non covered reasons provider contract ↓
↓ ↓ ↓ Follow AR
What is the May I Check payment history Scenario Tool
time frame to have the if payment received for same
submit the claim# & CPT with same provider from
corrected claim? call ref#? same insurance
↓ ↙ ↘
May I have the Yes No
Claim# & Call ↓ ↓
ref#? Could you please send claim What is fax# or Appeal
back for reprocessing since address to send the appeal?
we have received payment for ↓
same procedure? How much is the appeal limit?
↓ ↓
Rep Agrees? May I have the
↙ ↘ claim# & call ref#?
Yes No
↙ ↘
What is the TAT What is fax# or Appeal
for reprocessing? address to send the appeal?
↓ ↓
May I have the How much is the appeal limit?
claim# & call ref#? ↓
May I have the
claim# & call ref#?

Important Notes & Actions:

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 CHAPTER 7

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network then click on the link to follow the
provider's out-of-network scenario.
• If the claim is denied as non-covered charges under the patient plan
as DX or ICD-10 code is non-covered then it should be sent to the coding
team for alternative diagnosis code.
• If the coding team provides an alternative code then update it and
resubmit a corrected claim.
• If the coding team does not provide an alternative code then bill the
claim to the secondary or consecutive payer if available or else release it to
the patient.
• If the claim is denied as non-covered charges under the patient plan
for other reasons then bill the claim to the secondary or consecutive payer if
available or else release it to the patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
• If no other payer is active or available on DOS then release the claim
to the patient.
• If the claim is denied as non-covered charges as per the provider
contract and if payment is received in the payment history and the rep agrees
to reprocess the claim then set the follow-up for the TAT provided by the
rep.
• If the claim is denied as non-covered charges as per the provider
contract and if the payment is received in the payment history but the rep
denies to reprocess the claim and asks to send an appeal then submit an
appeal to insurance.
• If the claim is denied as non-covered charges as per the provider
contract and if the payment has not been received in the payment history
then you can either submit an appeal or write off the claim. So work as per
your client's instructions.
• Non-covered as per provider plan denial cannot always have the CPT
issue or may differ, so follow the scenario tool as per denial reason.

242: Services not provided by network/primary

care providers (Provider is Out of Network)

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 CHAPTER 7

Denial Occurrence:
• This denial occurs when the provider who rendered the service is not
contracted with the insurance.
• In this scenario, the claim can be paid if the patient's policy covers
out-of-network benefits.
• If the patient's policy does not cover out-of-network benefits then the
claim can be billed to the patient.
• In the HMO or EPO plan, out-of-network benefit is not covered.
• In the PPO or POS plan, out-of-network benefit is covered.

On Call Scenario:

Claim denied as non covered services

as per patient plan as provider is out of network
↓
May I get the denial date?
↓
Does patient plan cover out of network benefit?
↓
What plan does patient has? (HMO, PPO, EPO, POS)
↙ ↙ ↘ ↘
↙ ↙ ↘ ↘
HMO PPO EPO POS
↙ ↓ ↓ ↘
May I have the Could you please May I have the Could you please
claim# & call ref#? reprocess the claim claim# & call ref#? reprocess the claim
since patient plan since patient plan
does cover out of does cover out of
network benefit? network benefit?
↓ ↓
What is the TAT What is the TAT
for reprocessing? for reprocessing?
↓ ↓
May I have the May I have the
claim# & call ref#? claim# & call ref#?

Important Notes & Actions:

• Please take action as per your process update. Below actions can
be different from your process update.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network and the patient has a PPO or POS plan and

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the rep agrees to reprocess the claim then set the follow-up for the TAT
provided by the rep.
• If the claim is denied as non-covered charges under the patient plan
as the provider is out of network and the patient has an HMO or EPO plan
then bill the claim to the secondary or consecutive payer if available or else
release it to the patient.
• Before billing the claim to a Secondary or Consecutive payer, need to
verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the
payer website if access is available or else call the insurance.
• If no other payer is active or available on DOS then release the claim
to the patient.

226: Information requested from the

Billing/Rendering Provider was not provided or
not provided timely or was
insufficient/incomplete
On Call Scenario:

Claim denied as Medical Records Requested

↓
May I get the denial date?
↓
What is the Fax# or Mailing address to send the MR?
↓
How much is the time limit to send the records?
↓
May I have the claim# & call ref#?

Important Note:

• Calculate the time limit from the denial date, if it is not crossed then
send the MR or else write off the claim if the time limit is crossed.
• Sometimes the client wants us to send MR even if the time limit is
crossed, so work accordingly.

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• Always check the remark code given with the denial reason,
sometimes it provides the exact reason for denial that could differ. So follow
the AR scenario tool to work the exact denial.

18: Exact duplicate claim/service

On Call Scenario:

Claim denied as duplicate

↓
May I get the denial date?
↓
Check if CPT of your charge billed
more than once on same DOS
↙ ↘
No Yes
↙ ↓
What is the original Check if modifier, rendering provider
status of the claim? and medical records are same
↓ ↙ ↘
Follow AR scenario tool No Yes
for original claim status ↓ ↓
Can you please reprocess May I have the
the claim since modifier, claim# & call ref#?
rendering provider and medical
records are different?
↓
Rep Agrees?
↙ ↘
Yes No
↙ ↙ ↘
What is the TAT Rep asked to Rep asked to
for reprocessing? send corrected submit an appeal
↓ claim ↓
May I have the ↓ What is the Fax# or
claim# & call ref#? What is the Mailing address to
time frame for send an appeal?
corrected claim? ↓
↓ How much is the
May I have the time limit?
Claim# & Call ref#? ↓
May I have the
Claim# & Call ref#?

Important Note:

• When the modifier, rendering provider, and medical records are the
same for both the CPTs billed on the same DOS then the charge should be
voided.

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• Sometimes, the client wants us to get the coding team clarification to

determine whether these are duplicate charges or not, so work as per client
instructions.
• When rendering providers on both the charges are different then add
77 modifier and resubmit the corrected claim.
• When rendering providers on both the charges are the same but the
exam times are different then add 76 modifier and resubmit the corrected
claim.
• After sending the corrected claim, if the claim is again denied for the
same reason and the insurance rep denied reprocessing the claim then send
an appeal to insurance.
• When modifiers on both the charges are different and the rep denied
reprocessing the claim then send an appeal to insurance.
• Medicare does not accept the corrected claim, so send a fresh claim to
medicare.
• When sending an appeal, calculate the time limit from the denial date,
if it is not crossed then send the document, or else write off the claim if the
time limit is crossed.
• Sometimes the client wants us to send the document even if the time
limit is crossed, so work accordingly.
• Sometimes, the Rep provides status as claim denied as duplicate as it
is already paid to another provider. So follow the AR scenario tool for paid
to another provider status.

24: Charges are covered under a capitation

agreement/managed care plan
On Call Scenario:

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Claim paid directly to provider under Capitation contract/Claim

denied as patient covered under capitation or managed care plan
↙ ↘
Medicare/Medicaid Payer Other Payers
↓ ↓
May I get the denial date? May I get the processed and paid date
↓ ↓
Which managed care payer What is the AA, PA and Patient Responsibility?
is active on DOS? (Coins, Deductible or Copayment)
↓ ↓
Can I get policy ID, claim mailing May I know whether this procedure code is
address for managed care insurance? covered under Capitation or Fee for service?
↓ ↙ ↘
May I get the Claim# & Call ref#? Fee for service (FFS) Capitation
↓ ↓
Could you please send May I know the start and end
claim back for reprocessing? date of the capitation contract?
↓ ↓
What is the TAT for Check if DOS lies between
reprocessing? capitation contract start and
end date
↙ ↘
No Yes
↙ ↓
Could you please send May I get the
claim back for reprocessing? Claim# & Call
↓ ref#?
What is the TAT for
reprocessing?
↓
May I get the Claim#
& Call ref#?

Important Note:

• When this denial is given by Medicare/Medicaid insurance then

check the web portal if access is available and you will get managed care
information as HMO/MCO plan.
• When it is Medicaid payer then managed care insurance can be billed
with the same policy ID as Medicaid insurance except for BCBS payer.
• When it is Medicare payer then managed care has a different policy
ID, you can find out the correct policy ID on that insurance portal or on call.
• When this denial occurs from other payers and CPT is covered under
Capitation then it is processed under contract where a fixed amount has been
decided to pay to the provider then this claim should be written off.
• Fee for service is a plan where insurance pays each service given by
the provider, so it's the insurance's responsibility to pay each claim.

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97: The benefit for this service is included in the

payment/allowance for another
service/procedure that has already been
adjudicated
On Call Scenario:

Claim denied as Bundle/Inclusive

↓
May I get the denial date?
↓
To which CPT is it bundled with?
↓
What is the time limit to send corrected claim?
↓
What is the fax# or mailing address to send an appeal?
↓
May I have the claim# and Call ref#?

Important Note:

• This denial should be sent to the coding team to check if the claim
can be resubmitted by updating the modifier or not.
• If you have access to the encoder, findacode, etc. tools then you can
also check the NCCI edit between procedures. These tools will help you to
identify whether NCCI edit exists between CPTs billed on the same DOS or
not. If yes then whether it can be overridden using the appropriate modifier
or not. It also provides the most suitable modifier to override the CPT. If
CPT cannot be overridden then it should be written off.
• If the coding team response is received with a correct modifier or you
identify the correct modifier through any tools then update it and send the
corrected claim to insurance. Medicare does not accept the corrected claim,
so send a fresh claim to medicare.
• If the coding team response is received as coding is correct or you
identify that there is no NCCI edit existing through any tools then call the
insurance and ask them to reprocess the claim. if they deny then send an
appeal to insurance.

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