Terminology
What does HCPCS stand for?
Healthcare Common Procedure Coding System
What is Medicare?
A federal health insurance program for people 65+ or with certain disabilities
What is the first step in the billing process?
Patient intake and verification of insurance
What is Medical Necessity?
Justification that a service or item is reasonable and necessary for the patient
What is a Denial?
A claim that has been rejected by the payer
Define Modifier
A code that provides additional information about a procedure or service
What is Medicaid?
A joint federal and state program that helps with medical costs for low-income individuals
What is Prior Authorization?
Approval from the payer before providing certain services or equipment
Define Justification
Supporting documentation explaining why a DME item is needed
List common reasons for Denials
Missing documentation, incorrect coding, lack of medical necessity
What is a Claim?
A request for payment submitted to an insurance company
Define Commercial Insurance.
Private health insurance provided by non-governmental entities
Define Reimbursement
Payment received from a payer for services rendered
What is a Referral?
A written order from a primary care provider for a patient to see a specialist or receive equipment
How do you handle a Denial?
Review the reason, correct the issue, and resubmit or appeal
Explain Denial
A refusal by a payer to reimburse for a service or item
What is Coverage?
The extent to which health services and items are paid for by insurance
What is a Clean Claim?
A claim that is complete, accurate, and submitted without errors
Explain the importance of Documentation
Ensures compliance, supports claims, and reduces denials
What is an Appeal?
A formal request to reconsider a denied claim
What is an Appeal?
A request to review and reconsider a denied claim
Explain Eligibility
A patient's qualification for insurance benefits based on specific criteria
Explain the role of a Payer
To review, process, and reimburse claims submitted by providers
What is an Intake form?
A document collecting patient and insurance information at the start of service
Explain the Denial Management process.
A process to track, analyze, and resolve denied claims efficiently