Service Types
The walk-in clinics that are located outside of hospitals and emergency departments
What is Urgent Care?
These services are required to be billed monthly or at the end of treatment.
What is recurring charges?
Primarily handles backend patient requests.
What is PEX- Patient Experience Team?
The COB when billing Tricare for Life with Medicare
What is Secondary?
The date on which a policyholders coverage begins.
What is Effective Date?
The exam by a doctor and includes bloodwork and other tests.
What is an Annual Physical?
The billed amount/charges that are not paid by Medicare or any other insurance company for certain medical services depending on various conditions.
What is Non-Covered Charges?
The Subject Matter Experts (SMEs) handles escalations, Repeat Calls and Accounts with bot notes as a means of ensuring resolution.
What is Tier 1 (T1) Helpdesk?
This occurs when the same service on the same date of service is billed more than once.
What is a duplicate claim?
Any specific situation, condition, or treatment that a health insurance plan does not cover.
What is Exclusion or Limitation?
Hospital outpatient services you receive while your doctor decides whether to admit or discharge you.
What is Observation Services?
The provider or facility has no contract with your health plan.
What is Out of Network?
The process that allows you to escalate accounts that require additional attention to PEX per its level.
What is a CSUSR?
Resubmitting a claim after obtaining the correct information
What is a Rebill?
Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.
What is Preventive Care (Preventive Service)?
These are providers that have a contract with your insurance company
What is In Network?
The provider bills a patient for the difference between the provider's charge and the amount the patient's health insurance will pay.
What is Balance Billing?
The reference to the process of identifying, addressing, and rectifying a service failure, and restoring patient satisfaction.
What is Service Recovery?
PT account returned after INS submission for billing advises no PT information found from payer
What is an Insurance Kickback?
The insurance company refuses to pay for a claim made by a policyholder
What is a denial?
The inclusion of checking routine measurements such as height, weight, blood pressure and assessments.
What is an Annual Wellness Visit?
The patient was not notified prior to or at the time of service about what their costshare or patient responsibility after services have been rendered and receives unexpected bill?
What is NSA- No Surprise Act?
The additional resource will be asked to engage patients that have had an account escalated and/or phone agents require additional assistance in resolving the reason for patient contacting CRC.
What is Tier 2 Support?
The patient disagrees with a medical bill and requests to have the account reviewed
What is Dispute?
It defines what health care services are reasonable, necessary, and appropriate based on clinical standards of care.
What is Medical Necessity?