![]() ![]() Insurance companies (payers) offer various levels of coverage to their members, and as the medical biller/coder, you must be able to navigate payer contracts to gather the information you need to prepare and follow-up on claims. Reading Payer Contracts for Key Medical Billing and Coding Details Department of Labor program that insures employees who are injured at work. If the patient visits a non-contracted provider, the claim is considered out-of-network. PPO (preferred provider organization): A health management plan that allows patients to visit any providers contracted with their insurance companies.POS (point of service): A health insurance plan that offers the low cost of HMOs if the patient sees only network providers.OON (out-of-network): An out-of-network provider is one who does not have a contract with the patient’s insurance company.INN (in-network): A provider who has a contract with either the insurance company or the network with whom the payer participates. ![]() HMO (health maintenance organization): A health management plan that requires the patient use a primary care physician who acts as a “gatekeeper.” In HMOs, patients much seek treatment from the primary physician first, who, if she feels the situation warrants it, can refer the patient to a specialist within the network.Under HIPAA, patients must be allowed access to their medical records. HIPAA (Health Insurance Portability and Accountability Act): The law, sometimes called the Privacy rule, outlining how certain entities like health plans or clearinghouses can use or disclose personal health information.RA (remittance advice): A document, issued by the insurance company in response to a claim submission, that outlines what services are covered (or not) and at what level of reimbursement.EDI (electronic data interchange): The electronic systems that carry claims to a central clearinghouse for distribution to individual carriers.CMS (Centers for Medicare & Medicaid Services): The division of the United States Department of Health and Human Services that administers Medicare, Medicaid, and the Children’s Health Insurance Program.The form correctly identifies the payer and includes the right payer identification number and payer mailing address.ġ0 Must-Know Medical Billing and Coding Acronyms.The claim form includes all the required information (patient name, address, date of birth, identification number, and group number) in the correct fields.The patient’s coverage was in effect on the date of service, and the patient’s insurance covers the service provided.In addition, the form includes no expired or deleted codes. Every procedure code has a supporting diagnosis code, which eliminates any questions about medical necessity. ![]()
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |