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• 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 .
13. PREMIUM : Money paid by the member to keep policy active .
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14. DOS : {DATE OF SERVICE} The date when patient gets treatment from the provider the
format be as (month /date/year - Aug/24/2023) .

15. 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.

16.ACCOUNT NUMBER : This is like a reference number assigned by the provider when the
patient is registered with the provider software and creates an account to record the
treatments.
17. CLAIM : It is a pre- defined document submit to the insurance by the provider for
reimbursement amount .
18. TIMELY FILLING LIMIT (TFL) : Time set by the insurance to submit the claim by the
provider TFL calculated from (DOS).
*. 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.

19.APPEAL : A provider submitting a request for reconsideration it I calculated from date of

denial.

* 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
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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
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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 :

30. MEDICARE ADVANTAGE PLAN :

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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.

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

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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

*NAVY

*AIR FORCE

36. COBRA :

(CONSULATED OMNIPUS BUDGET RECONSULATION ACT )

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If any employee loses his/her job still he can get his/her medical expenses covered by the previous
employer (company) by 36 months.

37. CLIA :

(CLINICAL LABORATORY IMPROVEMENT AND AMENDMENT ACT)

It is the certification given by the CMS to every laboratories every year.

38. BIRTH RULE :

For any new born baby whose birth date comes first in their parents then their insurance
automatically starts covering the child.

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 :

*
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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

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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
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