Update RCM Reference book PDF

Summary Claim Form Part 1 RCM Steps Part 2 Place of Service Part 3 All CPT Wise Description Part 4 Types of Plans Part 5 Modifiers Part 6 Types of Insurance Part 7 Abbreviations...

Summary Claim Form Part 1 RCM Steps Part 2 Place of Service Part 3 All CPT Wise Description Part 4 Types of Plans Part 5 Modifiers Part 6 Types of Insurance Part 7 Abbreviations Part 8 Denial Code with Scenario Part 9 US Geographical Conditions Part 10 Team Leader Part 11 Quality Part 12 Excel Part 13  CMS 1500 Form 1 Types of insurance 21 DX Code 1.a Insured/Policy ID 22 Medicaid Resubmission Code 2 Patient Name 23 Prior Authorization 3 Patient DOB 24.a Dos 4 Insured Name 24.b Place of Service 5 Patient Address 24.d CPT Code 6 Patient Relationship to insured 24.e DX Pointer 7 Insured Address 24.f Charges 8 Patient Martial Status 24.g Number of units 9 Other Insured Name 24.j Rendering Provider id 10 Patient Condition Related to 25 Federal Tax id 11 Insured Policy Group or FECA# 26 Patient Account # 12 Release of Information (ROI) 27 Accept Assignment 13 Assignment of Benefits (AOB) 28 Total Charge 14 Date of Illness/Injury (Accident or Pregnancy 29 Amount Paid 15 If patient has similar illness given first time 30 Balance Due 17 Name of Referring Provider 31 Signature of Physician 17.b Referring Provider NPI 32 Service Facility Location 18 Hospitalization date Related to current service 32.a Service NPI 19 Reserved for Nucc use 33 Billing Facility Location 20 Outside Lab 33.a Billing Facility NPI  Steps of RCM: Revenue Cycle Management 1 - Appointment & Scheduling 2 - Eligibility Check & Benefit Verification 3 – Registration 4 – Encounter 5 - Medical Transcription 6 - Medical Coding 7 - Charge Capture/ Charge Entry 8 - Claim Generation & Submission 9 – Insurance 10 - Payment Posting 11 - Account Receivables 12 - Denial Management 1- Appointment and Scheduling : * Patient takes an appointment with the provider for health issue. Collection of relevant demographics and insurance information and appointment and scheduling. Putting notes for reminder call to be placed to the patient one day prior to appointment Example: Patient complete name, Patient SSN, Patient DOB, Callback#, Patient Ins Name, Policy id and name, Symptoms of Disease. 2 - Eligibility Check and Benefits Verification *Overview of Insurance information collected during appointment. Document the correct Eligibility and Benefits by taking patient acknowledgement. Financial Advice discussion with the patient 3 – Registration * Patient filed his demographic and payer details at the time of visits. Patient submits the card copies. Registration step is completed only after all the patient information is entitled into the provider's software 4 - Encounter * It is the stage where the patient & Provider meet with each other. Provider mention all the treatment related information in a document call super Bill / Encounter Form. The Discussion Between the provider and patient is recorded in an instrument called as Dictaphone. 5 - Medical Transcription * The voice files are converted into text files. These files form the Medical Records/Reports 6 - Medical Coding * The process of converting text into codes in medical billing Example: Dx Code, CPT Codes, Modifiers 7 - Charge Entry/Charge Billing * The process of entering the charges into provider's software is called Charge Entry Terms Related to Charge Entry Bill Amount (BA) : It is the total cost of treatment Referring Provider Name/ Referring Provider NPI Rendering Provider Name/ Rendering Provider NPI Place Of Service Tax ID DOS Dx , CPT Codes and Modifiers 8 - Claims Generation and Submission *Claim Submitted by Electronically from clearing House or Paper claim in the form of CMS 1500 Form /UB 04 with the ins. 9 – Insurance *Claim Adjudication Takes Place in it for payment. 10 - Payment Posting * The process of entering the payment details or information into billing system is known as Payment Posting. We will post the payment with the help of EOB/ERA's and Correspondence received by payer Three natures of Payments are : Full Payment Over Payment Low Payment 11 - Account Receivables (AR) * AR involves in collecting money owed to the provider by the insurance for the service rendered to the patient. 12 - Denial Management *Please refer to Denial Scenario page.  Place of Service 09,10 Prison 11 Office 12 Home 21 Inpatient 22 Outpatient 23 Emergency Room 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment facility 31 Skilled Nursing Facility 32 Nursing Facility 34 Hospice 41 Ambulance Land 42 Ambulance Air or Water 51 Inpatient Psychatric Facility 52 Psychatric Facility 65 ESRD Treatment Facility Timely Filing Limit Insurance Name Days Medicare 365 Days 90 days from date of denial or Medicaid payment BCBS 180 Days UHC 90 Days AARP 90 Days Cigna 90 Days Aetna 120 Days Humana 180 Days Tricare 180 Days Worker Comp 2 year from DOI GHI 365 Days HIP 365 Days  All CPT Wise Description Codes for CPT Codes for 00100 - 99100 - Pathology and 80000 - Anethesia 01999 99150 laboratory 89398 Surgery CPT 10000 - 80000 - Codes 69990 organ 80076 Codes for 70000 - 80100 - Radiology 79999 Drug testing 80103 Diagnostic 70000 - 81000 - Radiology 76499 Urinalysis 81099 Diagnostic 76500 - 85002 - Ultra sound 76999 Hematology 85999 Radiologic 77001 - 86000 - Guidance 77032 Immunology 86849 Breast 77051 - Transfusion 86850 - mammography 77059 Medicine 86999 Bone \ Joint 77071 - Anatomic 88000 - Studies 77084 pathology 88099 Radiation 77261 - 88104 - oncology 77999 Cythopathology 88199 Nuclear 78000 - Surgical 88300 - Medicine 79999 Pathology 88399  Office (POS 11) / Hospital Out Patient (POS 22) 3 New Establish Consultation Years Patient 99201 99211 99241 99202 99212 99242 99203 99213 99243 99204 99214 99244 99205 99215 99245 Emergency Codes (POS - 23) ER CPT Consultation 99281 99241 99282 99242 99283 99243 99284 99244 99285 99245 Hospital Inpatient POS 21 Admin CPT Follow Up ICU Discharge Consultation Subsequent 99221 99231 99291 99238 99251 99292 (for 99222 99232 Additional 99238 99252 Hours) 99223 99233 99253 99254 99255 Nursing POS 31 (Short term) & POS 32 (Long Term) Admin CPT Follow Up Discharge Annual Visit Consultation Subsequent 99304 99307 99315 99318 99251 99305 99308 99316 99252 99306 99309 99253 99310 99254 99255  TYPS OF PLANS What is HMO? Health Maintenance Organizations (HMO) An HMO is a Managed Care Plan that provides its members with comprehensive medical care services on a prepaid basis.HMOs require that you choose a Primary Care Physician (PCP) and provider location from those participating in the HMO provider network What is PPO ? PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician. Preferred Provider Organization (PPO) A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. What is POS ? Point-of-service plan (POS) A POS health plan stands for "point of service" and is a mix between an HMO and a PPO-style health insurance policy. With a POS health plan, you have more choices than with an HMO. You may need to select a primary care provider and need a referral to see a specialist. What is EPO ? EPO stands for "Exclusive Provider Organization" plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of- network benefits. What is Supplemental plan ? A Medicare Supplement Insurance (Medigap) policy helps pay some of the health care costs that Original Medicare doesn't cover, like: Copayments. Coinsurance. Deductibles.  Modifier Modifier - Modifiers may add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered. Modifier are two digit codes and are categorized into two levels 1. Level I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA - American Medical Association. 2. Level II Modifiers: Normally known as HCPCS Modifiers and consists of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS - Centers for Medicare and Medicaid Services. Both the above levels of Modifiers are recognized nationally. Sr. Modifiers Modifier are two digit codes and are categorized into two levels No Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation 1 24 and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service. Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s 2 25 condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. 3 26 Professional Component Modifier 27 is multiple outpatient hospital evaluation and management encounters on the same date.Use this Modifier when a patient received 4 27 multiple E/M service performed by the same or different physician in multiple outpatient Hospital setting.( Emergency Department ,Clinic etc) Bilateral procedure : Modifier 50 represents that the procedure was done 5 50 bilaterally. To report bilateral services, report the procedure code with the 50 modifier. 6 51 Multiple Procedures Decision for Surgery: An E/M service that resulted in the initial decision to 10 57 perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service  Distinct procedural service The physician may need to indicate that a procedure or service was distinct or 11 59 independent from other services performed on the same day. Use modifier 59 to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. Repeat Procedure or Service by the Same Physician:. This circumstance may be 12 76 reported by adding modifier 76 to the repeated procedure or service. Repeat Procedure or service by Another physician : This situation may be 13 77 reported by adding modifier 77 to the repeated procedure or services. 14 80 Assistant Surgeon 15 81 Minimum Assistant Surgeon 16 90 Reference (Outside) Laboratory 17 90 Repeat Clinical Diagnostic Laboratory Test 18 99 Multiple Modifiers 19 LT Left side 20 RT Right Side 21 GA Waiver of Liability Statement on file. Attending physician not employed or paid under arrangement by the patient's 22 GV hospice provider 23 GW Service not related to the hospice patient's terminal condition 24 TC Technical Component The QW Modifier states that the tests you are performing are simple laboratory examination and procedures that have an insignificant risk of an erroneous 24 QW result.They are considered CLIA waived and therefore require a CLIA Certificate of waiver.  TYPES OF INSURANCE Federal Ins : What is Medicare? Medicare is the federal health insurance program for: People who are 65 or older. Certain younger people with disabilities. People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). Medicare Part A: Medicare Part A hospital insurance covers inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery, home health care. Medicare Part B: Medicare Part B (medical insurance) is part of Original Medicare and covers medical services and supplies that are medically necessary to treat your health condition. This can include outpatient care, preventive services, ambulance services, and durable medical equipment Medicare Part C: Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare.... You'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare Medicare Part D: Medicare are eligible for prescription drug coverage under a Part D plan if they are signed up for benefits under Medicare Part A and/or Part B What is Medicaid? Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. What is Tricare ? Tricare (styled TRICARE), formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System. TRICARE Prime is a health insurance program offered to active duty members, retirees, activated guard & reserve members, and families. What is CHAMPVA ? The Civilian Health and Medical Program of the Department of Veteran's Affairs (VA) (CHAMPVA) is a comprehensive health care benefits program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. What is Worker's Compensation? Workers' compensation is insurance that provides cash benefits and/or medical care for workers who are injured or become ill as a direct result of their job. A claim is paid if the employer or insurance carrier agrees that the injury or illness is work-related. What is BCBS? Blue Cross Blue Shield Association (BCBSA) is a federation of 36 separate United States health insurance organizations and companies, providing health insurance in the United States to more than 106 million people. Blue Cross was founded in 1929 and became the Blue Cross Association in 1960, while Blue Shield emerged in 1939 and the Blue Shield Association was created in 1948. The two organizations merged in 1982. To reach the correct department of alfa prefix need to call at blue card # 1800-676-BLUE(2583) What is Liability insurance? Liability insurance is insurance that provides protection against claims resulting from injuries and damage to people and/or property. Bodily injury coverage – pays for injuries suffered by others in an accident you caused. Property damage coverage – pays for damage you cause to another person's property (typically their vehicle) in an accident. What is No - Fault ins ? No-fault insurance, sometimes referred to as personal injury protection insurance (PIP), can help cover you and your passengers' medical expenses, loss of income and more in the event of an accident, no matter who is found “at fault.”  Abbreviation 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. Assignment of Benefits (AOB) - Insurance payments that are paid directly to the doctor or hospital for a patients treatment. This is designated in Box 27 of the CMS-1500 claim form POS (Point-of-Service Plan)- A flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance. POS (Used on Claims) ( Place of Service) - This is used on medical insurance claims - such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctor’s office, 12 is for home, 21 is for inpatient hospital, etc. PPO (Preferred Provider Organization) - Commercial insurance plan where the patient can use any doctor or hospital within the network. (Similar to an HMO). PTAN (Provider Transaction Access Number) -Also known as the legacy Medicare number. A PTAN is a Medicare-only number issued to providers by Medicare Administrative Contractors (MACs) upon enrollment to Medicare. MAC s issue an approval/notification letter, including PTAN information, when an enrollment is approved. PTAN and NPI Relationship. Preauthorization - Requirement of insurance plan for primary care doctor to notify the patient’s insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense. Pre-existing Condition - A Medical condition that has been diagnosed or treated within a certain specified period of time just before the patient’s effective date of coverage. Provider - Physician or medical care facility (hospital) which provides health care services. Protected Health Information (PHI) - An individual’s identifying information such as name, address, birth date, Social Security Number, telephone numbers, insurance ID numbers, or information pertaining to healthcare diagnosis or treatment. Referral - When one provider (usually a family doctor) refers a patient to another provider. Modifier - Modifier to a CPT treatment code that provides additional information to insurance payers for procedures or services that have been altered or "modified" in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them. Network Provider - Health care provider who is contracted with an insurance provider to provide care at negotiated costs. Nonparticipation - When a healthcare provider chooses not to accept Medicare-approved payment amounts as payment in full. NPI Number (- National Provider Identifier)- A unique 10 digit identification number required by HIPAA and assigned through the National Plan and Provider Enumeration System (NPPES). Out-of Network (or Non-Participating) - A provider that does not have a contract with the insurance carrier. Patients are usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider. Out-Of-Pocket Maximum - The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurer’s obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions. Outpatient - Typically treatment in a physician’s office, clinic, or day surgery facility lasting less than one day. Palmetto GBA - An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina. Patient Responsibility (PR) - The amount a patient is responsible for paying that is not covered by the insurance plan. PCP ( Primary Care Physician)- Usually the physician who provides initial care and coordinates additional care if necessary. EOB Explanation of Benefits) - The statement that comes with the insurance company payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles. ERA (Electronic Remittance Advice)- This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to 835 standard.the HIPAA X12N Fee For Service - Insurance where the provider is paid for each service or procedure provided. Typically allows patient to choose provider and hospital. Some policies require the patient to pay provider directly for services and submit a claim to the carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays. Fee Schedule - Cost associated with each CPT treatment billing code for a provider’s treatment or services. GHP (Group Health Plan)-A means for one or more employer who provide health benefits or medical care for their employees (or former employees). Capitation - A fixed payment paid per patient enrolled over a defined period of time that is paid to a health plan or provider. This covers the costs associated with the patient’s health care services. This payment is not affected by the type or number of services provided. Authorization - When a patient requires permission (or authorization) from the insurance company before receiving certain treatments or services. CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) - Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Clearinghouse - This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is compliant with the strict HIPPA standards (this is one of the medical billing terms we see a lot more of lately). CMS (Centers for Medicaid and Medicare Services)- Federal agency which administers Medicare, Medicaid, HIPPA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration). You'll notice that CMS is the source of a lot of medical billing terms. CMS 1500 - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS- 1500's. The form is distinguished by its red ink. Coding - Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper diagnosis (ICD-9 or ICD-10 code) and treatment, such as CPT codes. This is for the purpose of reimbursing the provider and classifying diseases and treatments. 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 extends up to 36 months. Co-Insurance - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%. Contractual Adjustment - The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company. Coordination of Benefits (COB) - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary. Co-Pay - Amount paid by patient at each visit as defined by the insured plan. CPT Code ( Current Procedural Terminology)- This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. It was established by the American Medical Association. (COMMON MEDICAL BILLING TERM). Credentialing - This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. The CAQH credentialing is a universal system now accepted by insurance company networks. Credit Balance - The balance that’s shown in the "Balance" or "Amount Due" column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund. Crossover claim - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid. Deductible - Amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible. DME (Durable Medical Equipment) - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc. Electronic Claim - Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver. 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. E/M (The Evaluation and Management section of the CPT codes) - These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patient’s treatment needs. EMR (Electronic Medical Records) - Also referred to as EHR (Electronic Health Records). This is a medical record in digital format of a patient’s hospital or provider treatment. An EMR is the patient's medical record managed at the provider’s location. The EHR is a comprehensive collection of the patients medical records created and stored at several locations. HMO (Health Maintenance Organization) - HMOs have their own network of doctors, hospitals and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. (HMO) is a medical insurance group that provides health services for a fixed annual fee. Hospice - Inpatient, outpatient, or home healthcare for terminally ill patients. ICD-9 Code - Also known as ICD-9-CM-It is the International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number. ICD 10 Code - The 10th revision of the International Classification of Diseases. This is a 3 to 7 digit number. It includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10. In-Network (or Participating) - An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures. Inpatient - Hospital stay of more than one day (24 hours). IPA (Independent Practice Association) - An organization of physicians that are contracted with a HMO plan. Managed Care Plan – An insurance plan requiring a patient to see doctors and hospitals that are contracted with the managed care insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area. Maximum Out of Pocket - The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses. Medical Coder - Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD-9 codes (soon to be ICD-10) and corresponding CPT treatment codes and any related CPT modifiers. Medical Necessity – A medical service or procedure that is performed for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental. Medical Record Number - A unique number assigned by the provider or health care facility to identify the patient medical record. Medical Transcription - The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper. Medicare - Insurance provided by federal government for people over 65 or people under 65 with certain restrictions. There are 4 parts: Medicare Part A - Medicare Part A covers Medicare inpatient care, including care received while in a hospital, a skilled nursing facility, and, in limited circumstances, at home. Medicare Part B - Medicare Part B (medical insurance) is part of Original Medicare and covers medical services and supplies that are medically necessary to treat your health condition. This can include outpatient care, preventive services, ambulance services, and durable medical equipment. Medicare Part C: Part C plans are offered through private insurance companies and approved by Medicare. They are also known as Medicare Advantage or Medicare Health plans. Medicare Part D - Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B. Medicare Coinsurance Days -Inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters "Lifetime Reserve Days." Medicare Donut Hole - The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs. Medicaid - Insurance coverage for low income patients. Funded by Federal and state government and administered by states. Medi-gap - Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, co-insurance and balance bills, or other services not covered by Medicare. Super Bill – The form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms. Supplemental Insurance - Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare. Taxonomy Code - Specialty standard codes used to indicate a provider’s specialty sometimes required to process a claim. Term Date - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible. 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. TIN (Tax Identification Number)- Also known as Employer Identification Number (EIN). Group Name - Name of the group or insurance plan that insures the patient. Group Number - Number assigned by insurance company to identify the group under which a patient is insured. Guarantor - A responsible party and/or insured party who is not a patient. HCFA (Health Care Financing Administration)-Now known as CMS (see above in Medical Billing Terms). HCPCS (Health Care Common Procedure Coding System) - A standardized medical coding system used to describe specific items or services provided when delivering health services. It may also be referred to as a procedure code in the medical billing glossary. The three HCPCS levels are: · Level I - American Medical Associations Current Procedural Terminology (CPT) codes. · Level II - The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures. · Level III - Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs. Healthcare Insurance - Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. It can be an individual policy or family policy which covers the beneficiary's family members. It also may include coverage for disability or accidental death or dismemberment. Healthcare Provider - Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. It should not be confused with insurance providers or the organization that provides insurance coverage. HIC (Health Insurance Claim) - This is a number assigned by the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims. HIPAA( Health Insurance Portability and Accountability Act)- There are several federal regulations intended to improve the efficiency and effectiveness of health care and establish privacy and security laws for medical records. HMO (Health Maintenance Organization) - A type of health care plan that places restrictions on treatments. ACA - Affordable Care Act. Also referred to as "Obama Care". A Federal law enacted in 2010 intended to increase healthcare coverage and make it more affordable. It also expands Medicaid eligibility and guarantees coverage without regard to pre-existing medical conditions. Accept Assignment - When a healthcare provider accepts as full payment the amount paid on a claim by the insurance company. This excludes patient responsible amounts such as coinsurance or co-pay. Adjusted Claim - When a claim is corrected which results in a credit or payment to the provider. Allowed Amount (AA$)- The reimbursement amount an insurance company will pay for a healthcare procedure. This amount varies depending on the patient’s insurance plan. For 80/20 insurance, the provider accepts 80% of the allowed amount and the patient pays the remaining 20%. Aging – It is referred to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software's have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments. Ancillary Services - These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations –Examples: surgery, lab tests, counseling, therapy, etc. Appeal - When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the process and associated forms can be found on the insurance provider’s web site. Applied to Deductible (ATD) – This is usually found on the patient statement. This is the amount of the charges, determined by the patients insurance plan, the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider. Responsible Party - The person responsible for paying a patient’s medical bill. Also known as the guarantor. Revenue Code – The 3-digit number used on hospital bills to tell the insurer where the patient was when they received treatment, or what type of item a patient received. Scrubbing - Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer. Self-Referral - When a patient sees a specialist without a primary physician referral. Self Pay - Payment made at the time of service by the patient. Secondary Insurance Claim – A claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage. Secondary Procedure - When a second CPT procedure is performed during the same physician visit as the primary procedure. Skilled Nursing Facility - A nursing home or facility for convalescence. It provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care. SOF - Signature on File. Specialist - Physician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some healthcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist. Subscriber – Describes the employee for group policies. For individual policies the subscriber describes the policyholder. UB04 (Uniform Billing) - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.( Total 81 box ) Unbundling - Submitting several CPT treatment codes when only one code is necessary. Untimely Submission - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after these dates are denied. Up-coding - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payer. UPIN (Unique Physician Identification Number) - A 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number. Usual Customary & Reasonable(UCR) - The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient. Utilization Limit - The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit. V-Codes - ICD-9-CM coding classification to identify health care for reasons other than injury or illness. Workers Comp - Insurance claim that results from a work related injury or illness. Write-off - Typically referring to the difference between what the physician charges and what the insurance plan contractually allows, and what the patient is not responsible for. May also be referred to as "not covered". Spendown - Spend down means that you meet all eligibility requirements for Medicaid except for income. To become eligible for Medicaid your allowable medical expenses must be more than your spend down amount. Your spend down amount is the amount by which your monthly income exceeds the Medicaid allowance for living expenses. NCD and LCD - They are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.(National Coverage Determination & Local Coverage Determination). National Drug Code (NDC) - It is a unique 10 digit, 3-segment numneric identifier assigned to each medication listed under Section 510 of the US Federal Food , Drug and Cosmetic Act. The segements identify the labeler or vendor. Retro - If provider fails to take prior-authorization he can still give the treatment and then take permission within 72 hours. Release of Information (ROI) - Patient gives a permission that provider can use the patient medical documents for billing purpose only. If in case patient not signed ROI then the claim never go to insurance Advanced Beneficiary Notice (ABN) - Medicare patient gives in writing that if insurance does not make any payment and fault lies with patient then we can bill to patient Offset - The amount that insurance adjust in a current claim for a previous over paid claim. Recoup - The process where the provider returns backs the extra amount for overpaid claim to insurance Waiting Period - It is the duration Duration which a pre-existing condition will not be covered. Cooling Period - The period from date of Enrollment up to Effective date of policy. Waiver of Liability - Patient gives in writing that if insurance does not make any payment and fault lies with patient then we can bill to patient except Medicare ins What is CLIA ?- The Clinical Laboratory Improvement Amendments (CLIA) regulate laboratory testing and require clinical laboratories to be certificated by their state as well as the Center for Medicare and Medicaid Services (CMS) before they can accept human samples for diagnostic testing. What is SLMB? Specified Low-income Medicare Beneficiary (SLMB): A Medicaid program that pays for Medicare Part B premium for individuals who have Medicare Part A, low monthly income, and limited resources MQMB: Medicaid Qualified Medicare Beneficiary. NCCI Edits - National Correct Coding Initiative(NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payments in Part B claims Inclusive - Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, are not eligible for separate reimbursement. ( codes describing services considered to be inclusive to each other (that is, performed as part of a single procedure) can be billed separately). Global to Surgery- A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure.... These components of the surgical package are not eligible for separate reimbursement and will be denied if billed within the global period of the associated procedure. The global period is defined for each surgical Healthcare Common Procedural Coding System (HCPCS) code. It can be zero or ten days following a surgical procedure for minor procedures or endoscopies, or it can be ninety days for major surgeries. What is Radiology? A variety of imaging techniques such as X-ray radiography, ultrasound, computed tomography (CT), nuclear medicine including positron emission tomography (PET), and magnetic resonance imaging (MRI) are used to diagnose and/or treat diseases. What is Pathology? The causes and effects of diseases, especially the branch of medicine that deals with the laboratory examination of samples of body tissue for diagnostic or forensic purposes. What is Cardiology? Cardiology is a medical specialty and a branch of internal medicine concerned with disorders of the heart. It deals with the diagnosis and treatment of such conditions as congenital heart defects, coronary artery disease, electrophysiology, heart failure and valvular heart disease. What is W-9 Form and Description? A W-9 form is an Internal Revenue Service (IRS) form, also known as a Request for Taxpayer Identification Number and Certification form, which is used to confirm a person's taxpayer identification number (TIN) along with your name and address. What is CRNA ? Certified Registered Nurse Anesthetists (CRNAs) are advanced practice registered nurses with graduate level education who enjoy a high degree of autonomy and professional respect. CRNAs provide anesthetics to patients in every practice setting, and for every type of surgery or procedure What is MSP? Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. Value Code Report with Amount Payer Code Paid By 12 Working Aged A 13 ESRD B 14 No fault, Auto medical D 15 Worker's Compensation E 16 Federal Agency F 41 Black Lung H 42 Veterans Administration I 43 Disability G 47 Liability L  Denial Scenarios 1. CLAIM NOT ON FILE Conditions - If we are within/crossed the timely filing limit and policy is active for Dos 1. What’s the Patient’s policy effective date and termed date? Could you verify the mailing address (paper) of the Insurance company or if the claim sent electronic than please verify the payer Id. 2. What’s the timely filing limit of the claim? 3. Calculate if we are within the time limit /crossed (calculate from dos till today date ) 4. What kind of proof do they accept EDI(Electronic data interchange )/ Screenshot (software), mail acknowledgement 5. Call Reference # 2. CLAIM NOT ON FILE Conditions If the pt policy is not active for Dos. 1. What’s the Patient’s policy effective date and termed date? 2. Does the pt has any other policy with their insurance If yes could they provide policy id, TFL, mailing address or payer id ,Could we submit the claim through fax ,fax#, attention, Call Ref# 3.Does the pt has another Insurance could provide me the name of the Insurance , telephone and address 4. Call Ref# 3. PATIENT NOT IDENTIFIED /DOES NOT EXIST 1. Could you search the patient with SSN 2. Could you search the patient with DOB 3. Could you search with patient name first name and last name 4. Could you search with patient address 5. If with any of the details they are able to pull the patient than take the correct policy id , eligibility, whether they are primary or secondary for the patient , check the claim status and go according the scenario 6. Call Reference # 4. CLAIM DENIED FOR INVALID PATIENT ID# Condition- if the rep has the correct id# submit the claim with the ID# 1. Claim denial date 2. What was the id# under which the claim was received 3. What is the patient’s correct ID# under which claim needs to be submitted 4. What is the time frame to submit the corrected claim 5. What is the Address in which the corrected claim needs to be submitted 6. Do you accept the document through fax, Fax#, Attn 7. Claim# 8. Call Ref# 5. CLAIM DENIED FOR INVALID PATIENT ID# Condition - If the rep does not have correct id# we need to contact pt 1. Claim denial date 2. What was the id# under which the claim was received 3. What is the patient’s correct ID# under which claim needs to be submitted (If the rep does not have correct id# then we need to contact pt) 4. What is the time frame to submit the claim 5. What is the address need to submit the claim 6. Fax#, Attn 7. Claim# 8. Call reference # 6. CLAIM IN PROCESS Condition -If we have called within the time frame 1.When was the claim received? 2. What’s the normal processing time for the claim? 3. Calculate through Recd date till today date? 4. Call back once Tat is over to check the claim status? 5.What is the claim# 6. Call Ref #. 7. CLAIM IN PROCESS Condition-Delay 1.When was the claim received? 2. What’s the normal processing time for the claim? 3. Calculate from Received date till today current date, if it is delay than verify the reason for delay? 4. Do they require any assistance from our side. 5. Time frame 6. Address or Payer ID 7. Do they accept the document thru Fax# 8. Fax# and Attn details 9. What is the claim# 10. Call Ref # 8. CLAIM IN PROCESS - CLAIM APPROVED FOR PAYMENT 1. When was the claim received? 2. Process date 3. How much amt was approved for payment? 4. When we could expect the check? 5. Could you verify the check mailing address they have in their system? 6. Claim# 7. Call ref# 9. CLAIM DENIED FOR ADDITIONAL INFO Condition - If additional is needed from the pt 1. Claim denial date 2. What sort of additional information do they need 3. Do they need the information from the provider or the patient 4. Where can the information be updated 5. Is there any time frame to update the info 6. Claim# 7. Call Ref#. 10. CLAIM DENIED FOR ADDITIONAL INFO Condition- If additional is needed from the provider 1. Claim denial date 2. What sort of additional information do they need 3. Do they need the information from the provider or the patient 4. Where can the information be updated 5. Is there any time frame to update the info 6. Claim# 7. Call Ref#. 11. PAYMENT APPLIED TO DEDUCTIBLE Condition -Pt has not met his Yearly/ Lifetime Deductible 1. What’s the processing date? 2. What is the allowed amt of the claim? Is the amt partially applied or fully applied towards deductible? 3. Which type of deductible whether its yearly /lifetime deductible? 4. What was the total deductible? 5. How much pt has met including/excluding this claim? 6. Calculate it 7. If the pt has not met , claim, call ref#, 8. If the pt has met, ask the Insurance Rep to reprocess the claim, reprocess #, timeframe 9. Claim#, Call Ref# 12. CLAIM APPLIED TOWARDS CAPITATION 1. What’s the processing date? 2. Verify the start date and end date of the capitation period 3. If the DOS lies between than capitation period , take claim#, call reference # 4. If the DOS lies before or after the capitation period, than ask the claim to be reprocess the claim, Reprocess time frame, claim# and call reference #. If the provider is specialist than it could not be capitation, ask the Insurance Representative to Reprocess the claim. Reprocess #, time frame ,claim# ,call reference# 13. CLAIM PAID (provider) Condition- EFT 1. Process date 2. What is the Allowed amt and Pd amt, Co-ins, pt resp (take individual break up in case of multiple line). 3. Verify whether paid thru check or EFT 4. If EFT , verify the EFT# transaction ID, 5. Request for ERA , provide Fax# and Attn details 6. Claim# , 7. Call Ref# 14. CLAIM PAID (provider) Condition- Check 1. Process date 2. What is the AA$ and PD$, Co-ins, pt resp (take individual break up in case of multiple line). 3. Verify whether paid through check either single check or bulk , if bulk verify the bulk amt 4. Verify check mailing address 5. Verify check cashed----If it is cashed, verify encashment date, Request for Eob , more than 30 days front and back side of the check , Claim#, Call Ref#. If the check is still outstanding verify check 6. Verify encashed date--stop the check and request for reissue of check Provide Fax# and Attn details 7. Claim# , 8. Call Ref# 15. CLAIM PAID TO PATIENT 1. What is process date? 2. How much is allowed and paid to the member? 3. Why was it paid to the member? 4. Verify whether we can bill the member. Request for EOB, provide fax# and att to details 5. Claim # 6. Call Ref# 16. CLAIM PAID TO WRONG ADDRESS 1. What is the process date? 2. What is the AA$ and PD$, PTR ?(take individual break up in case of multiple line). 3. Was it a check or EFT, If EFT , verify the EFT# transaction ID, Request for ERA , provide fax# and Attn details 4. Verify whether paid thru check either single check or bulk , if bulk verify the bulk amt 5. Verify check mailing address 6. Verify check cashed----If it is cashed, verify encashment date, Request for Eob , more than 30 days front and back side of the check , Claim#, Call Ref#. If the check is still outstanding verify check 7. or Verify check encashed--stop the check and request for reissue of check , Provide fax# and Attn details 8. Claim# , 9. Call Ref# 17. CLAIM DENIED FOR COB INFO 1. Claim denial date 2. When was the last letter/correspondence sent to the patient? When and how many times? 3. Is there any response received from the patient 4. Address in which patient can update the info. 5. Could this document be send through fax, Fax#, Attn to? 6. Claim# 7. Call Ref# 18. CLAIM DENIED MAXIMUM BENEFIT MET 1. Claim denial date 2. In which terms has the Maximum benefits has been met (In terms of visits or Dollar value) 3. How much is the total Maximum benefit (In terms of dollar or visits) 4. How much pt has met till date ? 5. Calculate 6. If still benefits are pending than Reprocess the claim, rep#, timeframe, Claim#, Call Ref# 7. If benefits are met than Claim#, Call ref# 19. CLAIM DENIED AS PATIENT'S COVERAGE TERMINATED/NOT ELIGIBLE FOR DATE OF SERVICE/POLICY IS LAPSE 1 What is the denial date? 2. What is the effective date and termination date? 3. Does the pt have any other policy information for the patient within their Insurance? If yes could they provide the policy details 4. Claim# 5. Call Ref# 20. CLAIM DENIED FOR NO AUTH 1. What is the denied date? 2. Verify whether have they processed any hospital claim for the patient before?, if yes then get the Auth #, what they found in the claim & ask whether they can make correction in the claim and reprocess, Reprocess#, Time frame to process the claim, Claim #, Call Reference. If they are not ready to mention auth# in current claim than take time frame, address, Claim #, call reference. 3. If no than does your provider has taken any auth # for this dos, if yes then get the Auth #, & ask whether they can make correction in the claim and reprocess the claim, Reprocess#, Time frame to process the claim, Claim#, Call Reference. If they are not ready to mention auth# in current claim than take time frame, address , Claim #, call reference 4. if no provider has not taken any auth#, could we go for retro auth. Utilization Dept who provides for retro auth# Could you connect to the utilization dept , provide the entire details of your dos , if yes take the retro auth. If no than take the appeal limit ,appeal address, time frame , Claim #, call reference# 21. CLAIM DENIED FOR PRIMARY EOB 1.Claim denial date 2.What is the time frame to submit the Primary EOB 3.Address in which the EOB needs to be submitted 4. Claim# 5. Call Ref# 22. CLAIM DENIED FOR INVALID CPT 1. Claim denial Date 2. Which CPT was denied as invalid 3. What is the Valid CPT. 4. Time frame to submit the corrected claim along with the valid CPT 5. Address to submit the corrected claim. 6. Claim#. 7. Call Ref. #. 23. CLAIM DENIED MODIFIER MISSING 1. Claim denial date 2. Which CPT code was denied for Missing Modifier 3. What is the Modifier that needs to be added 4. What is the time frame to submit the corrected claim along with the Modifier 5. Address to submit the corrected claim 6. Claim# 7. Call Reference# 24. CLAIM DENIED FOR STUDENT QUESTIONER 1. Claim denial date 2. Was there any letter sent to the pt regarding this (if yes take the date). 3. Have you received any response from the patient regarding this 4. Where can the patient update this information, time frame, address, fax Att, 5. Claim# 6. Call Ref# 25. CLAIM DENIED FOR ACCIDENT DETAILS 1. Claim denial date 2. Was there any letter sent to the patient regarding this?. When and how many times? 3 Have you received any response from the patient regarding this letter. 4 Where can the patient update this information, time frame, address, fax Att, 5. Claim# 6. Call Ref# 26. CLAIM DENIED FOR MEDICAL RECORDS 1. Claim denial date 2. Which type of Medical records to they require. 3. Have they send any letter to the provider for informing this 4. Address 5. What is the time frame to submit the documents 6. Claim# 7. Call Ref# 27. CLAIM DENIED AS PRIMARY PAID MORE THAN SECONDARY ALLOWED 1. Claim denial date 2. What is the primary ins pd amt as per their info(if the payment details are there in system no need) 3. How much is the secondary insurance allowed amt 4. Will the patient be responsible for the balance 5. Claim# 6.Call Ref# 28. CLAIM DENIED AS PAYMENT INCLUDED IN GLOBAL SURGERY PERIOD 1 Claim denial date 2. When was the surgery performed? 3. What is the global period? 4. Ask rep can we appeal on this claim or need to take write off. 5. Claim# 6. Call Ref#. 29. CLAIM DENIED AS INCLUSIVE 1. Claim denial date 2. To which procedure code it is inclusive to? 3. Can we submit the claim along with a 1? 4. What is time frame to submit the corrected clm. 5. What is address to submit this info? 6. Claim#. 7. Call Ref# 30. CLAIM DENIED AS DUPLICATE 1. What is the denied date? 2. Could you verify some of the information’s from the original claim Procedure code, diagnosis code, modifier, provider name 3.If same could you provide the status of the original claim processed? Go according to the status 4.if information are different than ask the Insurance Rep to process the claim, Reprocess #, timeframe, claim#, call Reference# 31. CLAIM DENIED FOR MEDICALLY NECESSITY 1. Claim denial date 2. What sort of document do they need to Prove Medical necessity 3. What is the time frame to submit the document 4. What is the address in which the document needs to be submitted 5. Claim# 6. Call Ref# 32. CLAIM DENIED AS NOT RELATED TO TRUE EMERGENCY 1. Claim denial date 2. What sort of document do we need to submit to prove true emergency 3. Where do we need to submit the document 4. What is the time frame to submit the information 5. Claim# 6. Call Ref#. 33. CLAIM IS PENDING CLAIM PENDING OR SUSPENDED Sometimes the claims are suspended due 2 lack of information such as Primary EOB, Additional Medical documents or COB? 1. When was the claim suspended? OR 2. Since, when the claim is pending? Or pending date 3. What’s the reason for suspended or pended? 4. Time frame, Address, Fax#, Attn, Claim#, Call Ref# 34. PAYMENT OFFSET/ADJUSTMENT Payment offset mean insurance has processed the claim but ck was not issued or ck may be zero bal OR Less because they had already made an excess amt to the diff patient or same pt. 1. Process date 2. Payment details of the current claim (AA,PA,CO-INS,COPAY,DED)Offset Amt 3. Could you provide the account details for which excessive payment was done 4. Pt name, policy id, pt a/c ,dos ,billed amt ,allowed amt and paid. 5. Could you verify the mode of payment 6. Check mailing address 7. Send an Eob/ERA for the current a/c as well as for excessive account 8. Give your Fax , Attn details 9. Claim# 10. Call Reference # 35. CLAIM DENIED AS NON COVERED Condition- Denied as per provider’s plan 1. What is the denied date? 2.Was it denied as per the Patient’s plan or the Providers contract? If they say it was as per the Provider ’s contract 3. Could we submit any document which proves service was necessary 4. Time frame 5. Address 6. Claim# 7. Call Reference#. 36. CLAIM DENIED AS NON COVERED Condition- Denied as per patient’s plan 1. What is the denied date? 2. Was it denied as per the Patient’s plan or the Providers contract? 3. If they say it was as per the Pt Plan, then ask What’s the pat’s plan 4. Ask rep do we need to write off or can appeal. 5. Claim # 6. Call Ref#. 37. CLAIM DENIED CPT INCONSISTENT WITH DX CODE 1. Denial date. 2. Ask them do they have any idea about the CPT code which should be mentioned, 3. If yes get the CPT code and ask whether they can take the claim for reprocess. 4. If not then need to submit the claim with valid CPT or Diagnosis code, 5. Claim# 6. Call Ref# 38. CLAIM DENIED FOR INCORRECT PLACE OF SERVICE 1. Denial date. 2. Ask them what is the pos they find in the claim, 3. Ask them do they have any idea about the pos which should be mentioned, If yes get the pos and ask whether they can make correction and send the claim for reprocess. 4..If no, take the timeframe to submit the corrected claim 5. Address, Fax#, Attn 6. Claim# 7. Call Reference# 39. CLAIM DENIED AS INSRUANCE DON'T PAY FOR PA (PHYSICIAN ASSISTANT) 1. What is the denied date? 2. Was it denied as per the Patient’s plan or the Providers contract? 3. (If they say it was as per the Patient’s plan, then ask What was patient’s plan or If they say it was as per the Provider’s contract. 4. If they need any documents which proves that he is authorize to provide the service 5. Timeframe 6. Address, Fax #, Attn 7. Claim# 8. Call Reference# 40. CLAIM DENIED AS NOT MEDICALLY NECESSARY 1. Claim denial date 2. What sort of document do they need to Prove Medical necessity 3. What is the time frame to submit the above said document 4. What is the address to which the document needs to be submitted  5. Get the Claim# 6. Call Ref#. 41.CLAIM DENIED FOR UNTIMELY FILING LIMIT 1. Claim received date?. 2. Claim denial date:? 3. What is timely filing limit from dos? If within ask them to Reprocess the claim, Reprocess, time frame or TAT, Claim# ,Call Reference # 4. If we have crossed timely filing limit than could we submit the claim with proof 5. What kind of proof they accept EDI/Screen shot 6.What is appeal limit? 7. Claim# 8. Call Ref# 42. CLAIM DENIED FOR PRE-EXISTING CONDITION 1. Claim denial date? 2. What was the pre- existing condition?. 3. Was there any waiting period, check if any prior Dos was paid by the Insurance company , If yes than ask them to Reprocess the claim, time frame to reprocess the claim, claim#, call reference # 4. When was the letter sent to the pt?. if yes how many times and when? 5. Was there any response received from the pt.? 6. Could you provide me the timeframe and address on which we have to update this letter 7. Do they accept the document through Fax, Attn 8. Claim 9. Call Ref#. 43. CLAIM IS DENIED FOR NEW PATIENT QUALIFICATION WERE NOT MET. 1. Claim Denial Date? 2. When submitting new patient CPT codes 99201 through 99205. If there has been a prior face-to-face visit by you or the same specialty within your group within the previous three year period, do not submit a new patient code. Submit the applicable established visit code instead. Established Office Patients (99211-99215) These codes are used to bill for Established patients being seen in the office. An established patient is defined as someone who has been seen by you or a physician in the same specialty in your group within the previous three years. 3. Claim #. 4. Call Ref #. Topic US Culture  Time Zone - A time zone is a region that observes a uniform standard time or legal, commercial, and social purposes. Time zones tend to follow the boundaries of countries and their subdivisions because it is convenient for areas in close commercial or other * communication to keep the same time. In America ther are nine Time Zones. Below mentioned first four time zones for the * maintained U.S.A and the rest five fall outside of America. Pacific Time Zone -13 hours 30 Eastern Time Zone -10 hours 30 mins during mins during Standard time and 12 Standard time and 9 hours 30 mins during DST hours 30 mins during DST Alaska Time Zone Central Time Zone -11 hours 30 mins during Standard time and 10 hours 30 mins during DST Atlanta Time Zone Chamorro Time Zone Mountain Time Zone -12 hours 30 mins during Standard time and 11 hours 30 mins during DST Hawaii Time Zone Samoa Time Zone Points to Remember The time difference between India and EST is of 10 hours 30 mins (CST - 11 * hrs 30 mins, MST - 12 hrs 30 mins, PST - 13 hrs 30 mins) There is a difference of 1 hour between each Time Zone. Hence when it is * 0600 hrs in EST, it will 05:00 hrs in CST ,04:00 hrs in MST and 03:00 hrs in PST. There are four seasons in USA summer Autumn, Winter, Spring , Rain is not a * measure season in the country as its rains in any time of the year. DAYLIGHT SAVING TIME (DST): It is a widely used in system of adjusting the official local time forward usually one Hour , From of its official standard time for summer month.Typically clocks are adjusted forward one hour near the start of spring and hour adjusted backward in Autumn daylight saving time begins for most of the United states at 2 AM. On the second Sunday of March, Time reverts to standard time at 2 am on the first Sunday of * November. State Names and Abbreviation SR.NO State Abbreviation SR.NO State Abbreviation 1 Alabama AL 26 Montana MT 2 Alaska AK 27 Nebraska NE 3 Arizona AZ 28 Nevada NV 4 Arkansas AR 29 New Hampshire NH 5 California CA 30 New Jersey NJ 6 Colorado CO 31 New Mexico NM 7 Connecticut CT 32 New York NY 8 Delaware DE 33 North Carolina NC 9 Florida FL 34 North Dakota ND 10 Georgia GA 35 Ohio OH 11 Hawaii HI 36 Oklahoma OK 12 Idaho ID 37 Oregon OR 13 Illinois IL 38 Pennsylvania PA 14 Indiana IN 39 Rhode Island RI 15 Iowa IA 40 South Carolina SC 16 Kansas KS 41 South Dakota SD 17 Kentucky KY 42 Tennessee TN 18 Louisiana LA 43 Texas TX 19 Maine ME 44 Utah UT 20 Maryland MD 45 Vermont VT 21 Massachusetts MA 46 Virginia VA 22 Michigan Mi 47 Washington WA 23 Minnesota MN 48 West Virginia VA 24 Mississippi MS 49 Wisconsin WI 25 Missouri MO 50 Wyoming WY Team Leader Role and Responsibility What is Attrition? We can easily calculate the rate at which employees Who Left is number of Attrition plug the number into the following Formula Attrition rate = Number of attrition / Average Number of Employees * 100. Example : * Calculate the quarterly Attrition rate use the same formula however instead of the month data You will Work at the date for one quarter which is three Months.Suppose the BPO in the above example wants to calculate its attrition rate for the second quarter 2015.This would be April ,May and June 2015. The Beginning number of employees on April 2015 was 150 over the course of Quarter 30 People Left and 40 New Employees were Hired.Therefore the ending number of employees and June 2015 was 150 -30+40=160. * The Average number of Employee for the quarter was ( 150 + 160 /2 = 155. * The Attrition for the second quarter of 2015 was (30 / 155 ) * 100 = 19.35 percent. What is Shrinkage? * The Number of Leaves taken in a day , week and Month divide by the Number of member in team for day ,week and Month. * Number of team Member Working in days week and month. * Number of Leaves in day week and Month. * Shrinkage Percent. is = 20 * 15 is = 15 is = 300 /15 Is = 5%. What is SLA? ( Service Level Agreement) Contractual Service commitment ) An SLA is a document that describes the minimum performance criteria a provider promises to meet while delivering a service. It typically also sets out the remedial action and any penalties at that will effect. If performance fall below the promised standard. What is AHT? * The average duration of transaction measured from the customer initiation of the call including Hold Time ,talk time and related tasks that Follows the transaction. * Average handing time is the Time that a call center executive Takes to complete and interaction with the customer. * Formula: Average Handing Time : ( Total Talk Time + Total Hold Time + Total Wrap up Time ) is Divide by Number of calls Handled. What is Team Leader Roles and Responsibility? A Team Leader is someone who provides guidance, instruction, direction and leadership to a group of individuals the team for the purpose of achieving a key result or group of aligned results. A team leader is also someone who has the capability to drive performance within a group of people. 1- Allocation 2- Team Briefing at Day start and discussing Today Agenda. 3- Maintain Attendance Record on daily ,weekly and Monthly Basis. 4- Maintain Productivity Report on daily, weekly and Monthly Basis. 5- Leave Tracker on Monthly Basis. 6- Maintain Quality Data and provide feedback on error. 7- Maintain Break Log. 8- Team assistance on Queries 9- Hourly production Report. 10- Fun activity on daily basis for 5 to 10 min. 11- Rewards and Recognition. 12- Team motivation and development. 13- People management 14. Make other people feel important and appreciated. Quality Analyst What is Calibration? Calibration is a standardized scoring process and customer interaction evaluation that provides a quantitative measurement. It ensures that clients, quality monitoring team, supervisors, and trainers can evaluate agent performance and improve customer service. What is RCA? Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A root cause is a factor that caused a nonconformance and should be permanently eliminated through process improvement. Root cause analysis is a collective term that describes a wide range of approaches, tools, and techniques used to uncovercauses of problems What is DPO? It is the ratio of the number of defects in a sample to the total number of defect opportunities. As a result, the ratio here helps you count the average number of defects which occur in the total number of opportunities in a sample group. What is DPU ? DPU or Defects Per Unit is the average number of defects observed when sampling a population. DPU = Total # of Defects / Total population. What is Hybrid? The seven tools are: Cause-and-effect diagram (also known as the "fishbone" or Ishikawa diagram) Check sheet. Control chart. Histogram. Pareto chart. Scatter diagram. Stratification (alternately, flow chart or run chart) 1 - What is Cause and Effect Diagram ? Understanding the contributing factors or causes of a system failure can help develop actions that sustain the correction. A cause and effect diagram, often called a “fishbone” diagram, can help in brainstorming to identify possible causesof a problem and in sorting ideas into useful categories. What is 5 Why Analysis? 5 Whys is an iterative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?" Each answer forms the basis of the next question. 2 - What is Check Sheet? The check sheet is a form (document) used to collect data in real time at the location where the data is generated. The data it captures can be quantitative or qualitative. When the information is quantitative, the check sheet is sometimes called a tally sheet. 3 - What is Control Chart? The control chart is a graph used to study how a process changes over time. Data are plotted in time order. A control chart always has a central line for the average, an upper line for the upper control limit and a lower line for the lower control limit. 4 - What is Histogram? A Histogram is used to graphically summarize and display the distribution of a process data set. A Histogram is a bar chart showing the frequency of an outcome. 5 - What is Parretto Charts? The Pareto principle (also known as the 80/20 rule, the law of the vital few, or the principle of factor sparsity) states that, for many events, roughly 80% of the effects come from 20% of the causes. It is a decision-making technique that statistically separates a limited number of input factors as having the greatest impact on an outcome, either desirable or undesirable. 6 - What is Scatter Diagram? A scatter plot, also called scatter chart or scatter graph, is a type of mathematical diagram displaying values for two variables for a set of data, and make predictions based on the data. It consists of an X axis (the horizontal axis), a Y axis (the vertical axis) and a series of dots. 7 - What is Flow-Chart? A flowchart (also known as a process flow diagram) is a graphical tool that depicts distinct steps of a process in sequential order (from top to bottom of the page). The basic idea is to include all of the steps of critical importance to the process. Also, flowcharts are often annotated with performance information. What is a Role of Quality ? Work Without Defects. This means getting things right first time. It means doing the job completely and accurately the way the customer wants it. Daily and Weekly Activities are? 1 - Audit as per sampling 2 - Feedback Session with 5 why concepts. 3 - Error Review Session like Top 5 error categories. 4 - Daily, weekly and Monthly Report Published. 5 - Calibration ( Internal and External ) 6 - Provide coaching for bottom quota. 7 - Root Cause Analysis. EXCEL  Microsoft Excel Shortcut Keys Ctrl+A Select All None Ctrl+B Bold Format, Cells, Font, Font Style, Bold Ctrl+C Copy Edit, Copy Ctrl+D Fill Down Edit, Fill, Down Ctrl+F Find Edit, Find Ctrl+G Goto Edit, Goto Ctrl+H Replace Edit, Replace Ctrl+I Italic Format, Cells, Font, Font Style, Italic Ctrl+K Insert Hyperlink Insert, Hyperlink Ctrl+N New Workbook File, New Ctrl+O Open File, Open Ctrl+P Print File, Print Ctrl+R Fill Right Edit, Fill Right Ctrl+S Save File, Save Ctrl+U Underline Format, Cells, Font, Underline, Single Ctrl+V Paste Edit, Paste Ctrl W Close File, Close Ctrl+X Cut Edit, Cut Ctrl+Y Repeat Edit, Repeat Ctrl+Z Undo Edit, Undo F1 Help Help, Contents and Index F2 Edit None F3 Paste Name Insert, Name, Paste F4 Repeat last action Edit, Repeat. Works while not in Edit mode. F4 While typing a None formula, switch between absolute/relative refs F5 Goto Edit, Goto F6 Next Pane None F7 Spell check Tools, Spelling F8 Extend mode None F9 Recalculate all Tools, Options, workbooks Calculation, Calc,Now F10 Activate Menubar N/A F11 New Chart Insert, Chart F12 Save As File, Save As Ctrl+: Insert Current Time None Ctrl+; Insert Current Date None Ctrl+" Copy Value from Cell Edit, Paste Special, Above Value Ctrl+’ Copy Fromula from Edit, Copy Cell Above Shift Hold down shift for none additional functions in Excel’s menu Shift+F1 What’s This? Help, What’s This? Shift+F2 Edit cell comment Insert, Edit Comments Shift+F3 Paste function into Insert, Function formula Shift+F4 Find Next Edit, Find, Find Next Shift+F5 Find Edit, Find, Find Next Shift+F6 Previous Pane None Shift+F8 Add to selection None Shift+F9 Calculate active Calc Sheet worksheet Shift+F10 Display shortcut None menu Shift+F11 New worksheet Insert, Worksheet Shift+F12 Save File, Save Ctrl+F3 Define name Insert, Names, Define Ctrl+F4 Close File, Close Ctrl+F5 XL, Restore window Restore size Ctrl+F6 Next workbook Window,... window Shift+Ctrl+F6 Previous workbook Window,... window Ctrl+F7 Move window XL, Move Ctrl+F8 Resize window XL, Size Ctrl+F9 Minimize workbook XL, Minimize Ctrl+F10 Maximize or restore XL, Maximize window Ctrl+F11 Inset 4.0 Macro None in Excel 97. In sheet versions prior to 97 - Insert, Macro, 4.0 Macro Ctrl+F12 File Open File, Open Alt+F1 Insert Chart Insert, Chart... Alt+F2 Save As File, Save As Alt+F4 Exit File, Exit Alt+F8 Macro dialog box Tools, Macro, Macros in Excel 97 Tools,Macros - in earlier versions Alt+F11 Visual Basic Editor Tools, Macro, Visual Basic Editor Ctrl+Shift+F3 Create name by Insert, Name, Create using names of row and column labels Ctrl+Shift+F6 Previous Window Window,... Ctrl+Shift+F12 Print File, Print Alt+Shift+F1 New worksheet Insert, Worksheet Alt+Shift+F2 Save File, Save Alt+= AutoSum No direct equivalent Ctrl+` Toggle Tools, Options, View, Value/Formula Formulas display Ctrl+Shift+A Insert argument No direct equivalent names into formula Alt+Down Display None arrow AutoComplete list Alt+’ Format Style dialog Format, Style box Ctrl+Shift+~ General format Format, Cells, Number, Category, General Ctrl+Shift+! Comma format Format, Cells, Number, Category, Number Ctrl+Shift+@ Time format Format, Cells, Number, Category, Time Ctrl+Shift+# Date format Format, Cells, Number, Category, Date Ctrl+Shift+$ Currency format Format, Cells, Number, Category, Currency Ctrl+Shift+% Percent format Format, Cells, Number, Category, Percentage Ctrl+Shift+^ Exponential format Format, Cells, Number, Category, Ctrl+Shift+& Place outline border Format, Cells, Border around selected cells Ctrl+Shift+_ Remove outline Format, Cells, Border border Ctrl+Shift+* Select current region Edit, Goto, Special, Current Region Ctrl++ Insert Insert, (Rows, Columns, or Cells) Depends on selection Ctrl+- Delete Delete, (Rows, Columns, or Cells) Depends on selection Ctrl+1 Format cells dialog Format, Cells box Ctrl+2 Bold Format, Cells, Font, Font Style, Bold Ctrl+3 Italic Format, Cells, Font, Font Style, Italic Ctrl+4 Underline Format, Cells, Font, Font Style, Underline Ctrl+5 Strikethrough Format, Cells, Font, Effects, Strikethrough Ctrl+6 Show/Hide objects Tools, Options, View, Objects, Show All/Hide Ctrl+7 Show/Hide Standard View, Toolbars, toolbar Stardard Ctrl+8 Toggle Outline None symbols Ctrl+9 Hide rows Format, Row, Hide Ctrl+0 Hide columns Format, Column, Hide Ctrl+Shift+( Unhide rows Format, Row, Unhide Ctrl+Shift+) Unhide columns Format, Column, Unhide Alt or F10 Activate the menu None Ctrl+Tab In toolbar: next None toolbar Shift+Ctrl+Tab In toolbar: previous None toolbar Ctrl+Tab In a workbook: None activate next workbook Shift+Ctrl+Tab In a workbook: None activate previous workbook Tab Next tool None Shift+Tab Previous tool None Enter Do the command None Shift+Ctrl+F Font Drop Down List Format, Cells, Font Shift+Ctrl+F+F Font tab of Format Format, Cells, Font Cell Dialog box Shift+Ctrl+P Point size Drop Down Format, Cells, Font List