Insurance
Insurance Rules
Coding
100

Is it Okay to bill a Patient if all the research has been made to get a denial Paid and you cannot reach the patient by phone?

No, when you receive a denial returned to you, the claim adjustment reason code will be accompanied by a two-digit alpha-CO for “contractual Obligation” & PR For “Patient Responsibility", If the denial is reported as “CO” the payor is indicating that you have contractual obligation to accept the non-payment only if there is a PR than you can transfer the balance to the patent.

100

How does the birthday rule work

General Rule

  • Primary Coverage: The health insurance plan of the parent whose birthday falls earliest in the calendar year is considered the primary insurance for the dependent child.

Specific Scenarios

  1. Same Day Birthdays:

    • If both parents have the same birthday, the plan that has been in effect the longest is considered primary.
    • The year of birth is not considered in determining primary coverage.

  2. Divorced or Separated Parents:

    • If the parents are divorced or separated, the plan of the parent with legal custody is typically considered primary.
100

Definition of Procedure Codes

Represent the procedures, treatments, or services performed on the patient.  

200

The 3-Day Rule/72 hours Rule

It requires all diagnostic or outpatient services rendered during the DRG payment window (the day of and three calendar days prior to the inpatient admission) to be bundled with the inpatient services for Medicare billing.

200

Diagnosis codes are.

Indicate the nature of the illness or injury details.

300

what is CLIA

(Clinical Laboratory Improvement Amendments Act of 1988): An objective of CLIA is to ensure the quality standards to check accuracy,reliablity and timeliness of test results regardless of where the test was performed.

300

ICD-9-CM valid upto?

Valid till 09/30/2015

400

What is ABN & how it works

(Advance Beneficiary Notices): Form that required from Medicare that informs that patient about a particular procedure they may be able to undertake will not be covered by Medicare. Medicare requires an ABN to be signed by the patient prior to beginning the procedure before you can bill the patient for a service Medicare denies investigational or not medically necessary. Otherwise, Medicare assumes the patient did not know and prohibits the patient from being liable for the service. 

ABN must have the following three components: 

  • Detailed description of the service to be provided. 

  • Estimated cost with in < equals to 100. 

  • The reason is that it is believed Medicare will not cover the service. 

  • IF ABN is obtained attach modifier GA. 

  • IF ABN is not obtained, attach modifier GZ. 

500

Basics of COBRA coverage

 (Consolidated Omnibus Budget Reconciliation Act 1985): Gives employees the right to pay premiums for and keep the group health insurance that they would otherwise lose after they: 

  1. Reduce their work hours 

  1. Quit their jobs or lose their jobs 

  • Most people can keep the insurance for up to 18 months. Some people may be able to keep it for a few months. 

  • Federal legislation that governs the operation of group-sponsored health plans for businesses with twenty or more employees. The cobra plan will offer continuing healthcare coverage to you and your dependents if you leave the job. 

  • You will have to pay the entire COBRA Premium by yourself. 

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