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CONTRACTS
DENIALS
CODING
UB-04
CRCS-I
100
An agreement between an insurance plan and a healthcare provider that stipulates how services will be paid.
What is a contract?
100
Occurs when a claim is submitted beyond the allowed timeframe.
What is an untimely denial?
100
The Medicare database used to determine medical necessity for laboratory charges.
What is the NCD? (or National Coverage Determination)
100
Where the type of bill is located.
What is Box/Field 4?
100
The payment method also known as a DRG.
What is a Diagnosis Related Group?
200
A flat daily rate paid for each day of inpatient treatment.
What is per diem?
200
The disposition used for modifier 59 review.
What is 2COD?
200
A corrected claim requires what frequency digit?
What is 7?
200
Reported in Box 1?
What is the servicing address?
200
Is not primary to Tricare.
What is Medicaid?
300
The term used for a service which is paid in addition to other contracted rates.
What is a carve out?
300
This is required for advanced imaging services such as an MRI or PET Scan performed on a non-emergency basis.
What is a Prior Authorization?
300
These guidelines are used to determine if a procedure is inclusive or global to another procedure.
What are NCCI edits?
300
The admission code for an emergency found in field 19.
What is 1?
300
Also known as Title XVIII.
What is Medicare?
400
A bundled payment, typically for outpatient services, which is paid at a flat amount.
What is a case rate?
400
Occurs when medical records do not support an inpatient level of care.
What is a Medical Necessity denial?
400
Used to report patient symptoms and conditions.
What is ICD-10?
400
Reported on the UB in field 31 when an accident is related to an injury in the workplace.
What is occurrence code 04?
400
Also know as the Kennedy Kassenbaum Act.
What is HIPAA?
500
Contract language that caps reimbursement on large balance claims.
What is a stop loss?
500
Happens when surgery is performed to improve one's appearance.
What is a cosmetic denial?
500
A fourth digit added to a DRG which can increase reimbursement.
What is a Severity of Illness code?
500
A universal product identifier for human drugs in the United States reported in Box 43 for Medicaid plans.
What is an NDC?
500
The state that is exempt from DRG reporting.
What is Maryland?