Codes
This is a code used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient
What is a CPT code?
This modifier is used when a patient is seeing the same provider (for a follow-up appt) for an unrelated problem within the global period.
What is modifier 24?
This is a paper form that providers can circle the codes that were applicable.
What is a superbill?
You can check this on the payor portal to determine when the insurance plan became effective and/or terminated
What is eligibility?
These are the most common services that require authorizations
What are radiology exams (CT, MRI), surgical procedures, and other types of 'testing'?
The 6 main sections of CPT are
What are Evaluation and Management services, Anesthesia services, surgery, radiology services, pathology and lab services, medical services and procedures?
This modifier is one of the most common you will encounter and is used when a separately identifiable procedure was performed by the same provider on the same day.
What is Modifier 25?
The top section of this form holds the patient's demographic information in addition to the patient's insurance details.
What is a paper claim/HCFA/CMS 1500 form?
A provider’s office may submit a request for _____ through the insurance payer portal OR you can search to see if it is in place for a service that was already provided.
What are authorizations?
This certificate will authenticate that the in-office lab has been certified by the state to perform all laboratory testing onsite
What is CLIA (clinical laboratory improvement amendments)?
These codes represent services provided by a physician or other qualified healthcare professional for office visits, hospital visits, home services, preventive medicine visits.
What are Evaluation and Management (E/M) Codes?
This is associated with surgical procedures and is where any follow-up care associated with that procedure would be included in the fee that is paid for the surgical procedure itself.
What is the global period?
When claims go out electronically, the system will map the fields of the claim form into electronic ‘loops’ or ‘segments’ to report the necessary information to the insurance carrier.
What is an electronic claim?
In the portal we can check the _____ of a submitted claim to see if the claim was received, still pending, paid or denied
Claim status
This section on the EOB represents the contractual adjustment
Established
This modifier is used by a physician who performs the professional component of a service. This may include technician supervision, interpretation of results, and a written report.
What is modifier 26?
The middleman between the healthcare providers and the insurance payers. A clearinghouse checks the medical claims for errors, ensuring the claims can get correctly processed by the payer
What is a Clearinghouse?
You found that a claim was denied for untimely filing; but you are able to show proof that the claim was submitted within the appropriate timeframe and have an acceptance report from the clearinghouse, this could be contested with the payer using one of these dispute options on their website.
What is a reconsideration or appeal?
When an AR rep calls the insurance company to inquire about a claim this is part of the ___
What is follow-up?
These codes are a common system of codes that classifies every disease or health problem and represent a generalized description of the disease or injury that was the reason for the patient/physician encounter.
What are ICD-10 Codes?
This modifier includes the provision of all equipment, supplies, personnel and costs related to the performance of the procedure.
What is modifier TC?
The time frame set by individual insurance companies for a provider to submit claims. Claims must be submitted within the set time frame to be considered for reimbursement.
What is timely filing?
This plan is administered by United Healthcare, Also known as the NYSHIP Plan. This plan is most frequently the coverage for NY state employees. UHC and BCBS split the cost of services provided to the patient.
what is a split plan
These are the most common denial reasons
What are (Eligibility, Missing or invalid authorization number, Time Filing, Non-covered service (based on the member’s policy or insurance carrier’s guidelines, Not Medically Necessary, Bundling (service is considered inclusive of another service also billed; OR included in the global period), Claim is missing information, Diagnosis Code or Procedure Code Invalid? (Any of these answers is allowed- does not need to be all of them.