MEDICAL BILLING TERMINOLOGY Omega

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US SOCIAL SYSTEM
Social Security Number (SSN)
Ihis is a unique 9 digit number given by the Federal Government through the Social Security Office
for the purpose of identification and to maintain a portfolio of a person.
Format: XXX- XX- XXXX/ 123-45-6789.

American Name Format

All Americans have a 'First Name' and a 'Last Name'. The last name denotes their family namel
surname. They also have a middle name but this is optional.
Example: Amanda Smith is documented as Smith, Amanda
Brad Anthony Pitt is documented as Pitt, Brad A.

American Date Format

The Arnerican calendar format is MM/DD/YYYY (Month/Date/Year)

Example: 15th July 2019 is documented as 07/15/2019.

Telephone Numbers / Fax Numbers

Americans Telephone #s and Fax #s are 10 digit Numbers.
Format: 212-823-9847, 800-258-6211 (The first three digits represents the Area code)

Zip codes
In USA we have Zip Codes. These are 5 digits numbers that are specific to a certain area.
Example: 75284-4 128stands for Dallas, Texas. (The last 4digits represent the Post Office Box).

Time Zones

USA is a huge land mass and is therefore divided into 6 Time Zones.
EST - Eastern Standard Time
CST -Central Standard Time
MST - Mountain Standard Time
PST -Pacific Standard Time
AST- Alaskan Standard Time
HST- Hawaiian Standard Time
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Participants in the US Healthcare system

The US healthcare system revolves around
Patients
Providers
Payers/ Insurance Companies

Poyde wedil Cale to

Providers
Rattet
NASing hoes

Facility
Individual

1. Hospital
Center
1. Primary Care Physician (PCP) 2. Ambulatory Surgery
3. Skilled Nursing Facility
2. Specialty Care Physician (SCP) 4. Home Health

5. Hospice

Individual Providers
Primary care physician (PCP)
-Trained in general medical care
Treats routine problems

Specialty Care'Physician (SCP) to

than a primary care physician is certified
Has more advanced medical training Dentist etc
Cardiologist, Radiologist,
practice in acertain field of medicine.Ex:

Hospitals

Chronic Care
Acute Care Hospitals

Long term care

Intensive care on short term
basis

Carenot as intensive
Could indude an overnight stay

medcl whien the

are fuin fov
Every Seied Counts
tient s health S in Sericus dangr
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Ambulatory Surgery Center

Ambulatory surgery is surgery that does not require an overnight stay
It is also called day surgery, same-day surgery (SDS)
Eg: Eye surgeries, cataract, and laparoscopic surgeries, ears, nose, and throat
procedures
Skilled Nursing Facility
Primarily provides in-Patient treatment.
Lesser intensity than acute facility.
Usually for long-term basis
Less expensive
Visiting doctor or a doctor on call
To get qualified for SNF, a patient must be hospitalized for 3 consecutive days not
including the days of discharge.
Home Health
Prevertive,suPertive, vehabltative (or thera Retic care is Providd
Provides services at home Pal ieat at hane.
to
According to a written plan of treatment signed by the patient's physician
These services are provided at home for the disabled, old &injured
Provides medical, nursing, pathology, or therapeutic treatment and assistance with
essential activities of daily living
wth anestabl, sined Plan of ave
Hospice at plau ohese treamert qien
For terminally illpersons (patients with a life expectancy of 6 months or less)
Treatment for terminal illness stops during Hospice care
Only symptom management and treatment for any other illness is provided
-Examples: Cancer, HIV, ESRD (End stage renal disease)

Provider lds /Qualifiers:

Provider ldentification Number (PIN)

Issued by the Insurance company/ health plan
Issued to their contracted providers
Format is Insurance specific
Federal Tax id /Tax identification Number (TIN)
Assigned by the federal government for Tax purpose
Format is 9 digits (3-2-4) or (2-7)
National Provider ldentifier (NPI)
Issued by CMS and usage is mandated by HIPAA
The NPI is a single block of 10 digits
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Health Insurance
out patient services cte
Health insurance covers inpatient & bscrhel
Enrollee.
Insured/
The person covered by health insurance-
insured - Covered/ Dependents
The spouse & children of the
Each Insurance plan has:
Services covered

Non-covered Services

Premium

Patient responsibility on the bill

Provider network

The Insurance Card

the following information

The health insurance card will have
ldentification number

Group number

Plan type
Name of the Policyholder

Co-payment info
Co-insurance info

Deductible info

Supplemental Insurance
Primary, Secondary or
services.
Primary: The insurance plan
that is billed first for medical
billed after the primary insurance has paid or denied
Secondary: The insurance plan that is
payment.
usually picks up the veslon b
Supplemental: Another name for
secondary insurance. This plan
co-insurance.
patient's deductible and/or
Medicare supplement (Medigap) policy
is a private health insurance policy
Medigap: A coverage when Medicare is
designed specifically to fillin some
of the "gaps" inMedicare's
the primary payer.
responsible for
decide which insurance company is
A Coordination of Benefits (COB): A way to
insurance plan.
payment patient has more than one
if
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Payers med.tad, Be ass hlwe Shieid, Aetoa

tMod.ost,

Federal Private Liability

Medicare BCBs e coss Blu shed) ’ Auto Liability

Workers
Medicaid ’ Managed Care Organization Compensation

Tricare Commercial Insurance

Champva

Medicare
Nation's largest insurance program
CMS adminísters Medicare

insurance claim #s)

Medicare IDs are called as HIC#s (Health

Medicare Eligibility
Persons 65 year's and over
disability
Below 65, but have certain
ESRD - End stage renal disease

Medicare has four parts: Covevs

Inpatient hospitalization services
Part A(Hospital Insurance) -Pays for services not oveved by
Insurance)- Pays for Outpatient services, physician
Part B (Medical Pt- 4
(DME)
and Durable Medical Equipment
PartC- Medicare Advantage Plan
Part D- Prescription Drug Plan

Medicare

Part A (Hospital Insurance)

Receive Part A automatically
Need not purchase

Covers in-patient hospital expenses

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Part B(Medical Insurance)

Part B must be purchased
Covers the outpatient health care &other services not covered by Part A
Topurchase part Bone should have part Acoverage

Medicare Advantage Plans

Medicare Advantage Plans are sometimes called Medicare PartC
are approved oy
Medicare Part Cis covered by private insurance companies that
Medicare
cover Medicare
paid a fixed amount each month to
Tne private insurance companies are
beneficiaries
These plans must follow the rules set by Medicare
There are presently 3 types of Medicare Advantage Plans
HM0
PPO
POS

Medicare Secondary Payer (MSP)

responsible for paying first.
Medicare Secondary Payer is the term used when it is not
MCR actsas secondary payer for the following
Group health plans
Most of the SGHP

For LGHP &.EGHP plans

Black lung program

Workers Compensation plans

Auto liability plans Ex: no-fault insurance

CHAMPVA

Tricare

Railroad Medicare
retired Railway employees who are
Railroad Medicare: It's a Medicare program offered to
above 65

ld Format is 1 alpha+9 digits

Ex: A123-45-6789

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Medicaid
A Federal state program
For individuak and familhes with low incomes and resources

id Format is State SpecifC

Each state operates its own Medic aid program, with certain federal quicdeline
There is no patient's responsibility in most cases But in some cases 'spend down charges &
copay" are applied
Policyneeds to be renewed monthly but a few a also done yearly Any changes should be
reported to H5D (Human Services Department)
Many states aliow their Medicaid recipients to change their health plans (HMO or MCO} up
to every 30 days
Medicaid is always the Payer of Last Resort
CHAMPUS/ Tricare
Is provided to military personnel and their dependents ( Rami
Eligible beneficiaries must be listed in the DEERS Defense Enrollment Eligibility Reporting
System
Tricare Plans
Tricare Prime - For Active military personnel
Tricare Standard - For Retired military personnel
Tricare Extra- For Retired military personnel
Tricare for Life anho Medicare Part A& B
For Military retirees and their spousewho have

Services &Sppices that a med

most helh Cave
CHAMPVA

of Veterans Administration
Ahe Civilian Health and Medical Program ofthe Department
Eligibility
rated permanently and totally disabled for a
The spouse or child of a veteran who has been
service-connected disability
died from a service connected disability
The surviving spouse or child of a veteran who
Commercial Payer
Indemnity Plan
Managed care organization
Blue Cross Blue Shield

These are private for-profit companies

Theyoffer more than just health insurance
They may also offer auto, life, home etc.
Ex :Aetna, MCO, BCBS, Cigna, UHC etc.
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Indemnity Plan (Traditional or Commercial)

allowedamount.
In this plan the insurance company usually pays 80 percent of the
The patient is responsible for paving the remaining 20 percent.

Managed Care Organizations

by offering tailor made plans.
Itattempts to "manage a person's care"
Common types of managed care plans:

Health Maintenance Organizations (HMO) plans.

Preferred provider Organization (PPO) plans.
Point of Service Organization (POS) plans.
Health Maintenance Organizations

Covers only in-network providers responsibility to pay the entire cOst

patient's
providers become the
Services by out-network
of the service. T he/she is considered to
plan, in most cases
physician has a contract with an HMO
When the
be capitated
primary care physícian
A patient must first visit a within the network if
necessary
patient to a specialist
The PCP may refer (referral) that

Preferred Provider Organizations

an HMO
network of pYoviders
larger than the network in
Consists of a
PCP
There is no role of a
out of network
Covers both in-network/
he goes out of network
Patients' responsibility on
a bill would be higher if

Organizations PPO)
Point Of Service network providers (like a
in-network providers (like
an HMO), or out-of-
Covers both providers.
using in-network
Mandatory to meet PCP only when
network providers.
when using out of
No role of PCP network.
if he goes out of
responsibility on a bill would be higher
Patients'
Care Plans Medicare
Medicare Managed she/he can choose a
Medicare benefits,
becomes eligible for
When a person Plan
Medicare Advantage
managed care plan-
Medicare Part C
This is referred as
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MCO Plans - Recap

Out of network
Role of aPCP and In-network Providers
Plans providers
Referral

HMO

PPO

POS

Blue Cross Blue Shield

provides healthcare coverage for nearly 100
The Blue Cross and Blue Shield Association
million people
and in Puerto Rico
Healthcare coverageris available in all
50states, the District of Columbia
prefix.
characters, 6 to 17 digits, including the alpha
BCBS IDs - both alpha and numeric
Ex: XYZ123456789
insurance)
in which the patient took his
(the alpha prefix determines the state

federal employees.
BCBS Federal Employee Plan :For all the
Id format - "R" followed by 8 digits
Ex:R12345672

Blue Card
BCBS Plan to obtain health
that enables members of one
Blue Card is a national program service area.
living in another BCBS Plan's
care services while traveling or
Home Plan patient resides &
state where the
is taken by the patient in his/her
It usually refers to the plan that
pays premium.

Local Plan
treatment besides his/her Home plan.
state in which the patient takes
It usually refers to the plan/

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MEDICAL BILLING TERMINOLOGY

Liability Insurance
Auto liability
Worker's Compensation

Bodily injury to you and others.

property.
Damage to someone else's car or
vehicles that are damaged in
an accident.
The cost to repair your repaired.
damaged vehicle
is being
vehicle while your
The cost to rent a replacement

Auto aiabltty
and
companies
No Fault insurance
Own auto
submit a claim totheir
The drivers involved would
them.
receive compensation from
in No-Fault States
No-fault insurance is offered
stipulations and regulations.
Each state -own coverage
guaranteed
Immediate compensation is
Siunpli fed.
skewn is
Non-No Fa court to determine
the "fault".
a case in the
(involved in the accident) file
Both the parties
auto insurance of the party at fault pays
& the fault is proved, the
Once the case is settled
for both the parties.
compensation received
There is no immediate

Worker's Compensation
work-related problems
kinyuries
This plan covers only emplotees purcheu
Reasoni
No premiums for Employees
Nopatient responsibility
the employer
The policy - in the name of
employer getsaclaim #
Each injury reported by a
with medical records
Claims to be submitted along
Role of an "adjustor"
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Claim Forms

CMS -1500 UB -04

Used for physician billing

+ Used for Hospital Billing

33Blocks
81 Blocks

Place of Service Codes

Place of service is the location where the patient received treatment
Some of the most common place of service (POs) codes are:
11 office
21 Inpatient
22 Outpatient
24 Ambulatory Surgical Center
31: Skilled nursing Facility
34 Hospice

many times, or special

Durable Medical Equipment (DME) - Medical equipment that can be used
equipment ordered by your doctor, usually for use at home.

Advanced Beneficiary Notice (ABN) - An advancèd beneficiary r:otice is

a form, signed by you, that
covered by Medicare. The purpose of an
shows that the tests performed by your doctor may not be
services may not be covered and to advise you that you
ABN is to let you knowin advance that these
will be responsible for payment.
give to providers to submit the claims and get
Timely filing limit -The time frame that payers
reimbursed.

Insurance
endorsed by the National Association of
Birthday Rule -The Birthday Rule is date of birth
Commissioners (NAIC). The Birthday Rule
states that the plan of the parent whose
dependent children.
day) falls earlier (or first) in the calendar year is the primary plan for
(month and
covered under the
clause - Mother baby clause is rule in which a newborn baby is
Mother baby
of 30 days from the date of birth.
policy of the motther for a period

been admitted to the hospital &stays 24 hours or more.

Inpatient - Apatient, who has
hospital. Outpatient services
Outpatient (OP) - Patient who does
not need to stay overnight in a
surgeries.
include lab tests, X-rays, and some

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Explanation of Benefits (EOB)

Your health insurance adrninistrator sends you and your provider an toB.
EOB may identify:
Thepatient and the service provided.
Theamount charged by the provider.
Theamount of thecharpes that are covered and not covered under your plan.
The amount paid to your provider.
The amount you're responsible for.
Medical Necessity -Medical information justifving that the service rendered or item provided
1s
reasonable and appropriate for the diagnosis or treatrnent of a medical condition or illness.

Medically Necessary - Many insurance policies will pay only for treatment that
is deemed "medically
policies will not cover
necessary" torestore a person's health. For instance. manyhealth insurance
routine physical exams or plastic surgery for cosrnetic purposes.

falsifying
Fraud Knowingly billing for services not furnished, supplies not provided, or both, including
patient failed to
records toshow delivery of such items or billing Medicare for appointments that the
keep; and
provided or
" Knowingly billing for services at a level of cornplexity higher than the service actually
documented in the file.
Knowingly submitting false statements or making misrepresentations of fact to obtain a federal
health care payment for which no entitlement would otherwise exist;
referrals for items
"Knowingly soliciting, paying, and/or accepting remuneration to induce or reward
or services reimbursed by Federal health care programs;

"Making prohibited referrals for certain desighated health services

Billing for services not rendered
Altering medical records.
Use of unlicensed staff
Drug diversion (e.g. dispensing controlled substances with no legitimate medical
purpose) Kickbacks and bribery
Misusing codes ona claim, such as up coding or unbundling codes
Abuse describes practices that,either directly or indirectly, result in unnecessarycosts to the
Medicare Program/member. Abuse includes any practice that is not consistent with the goals of
providing patients with services that are medically necessary, meet professionally recognized
standards, and priced fairly.
Providing unnecessary services to members
Charging excessively for services or supplies.
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HIPAA
Accountability Act. Passed in 1996 HIPAA is a
HIPAAstands for Health Insurance Portability and
protect medical records and other personal health
federal law that sets a national standard to
information. The rule defines "protected health information"
Privacy Rule
"Protected Health Information", except as
Covered entities may not use or disclose
permitted or required by the Privacy Rule
or authorized by the individual.
Discharge or Death,Telephone
numbers ,Fax
Date of Birth, Admission,
PHI- Patient name,
Social security numbers.
numbers Electronic Email Addresses

Covered Entities Covered Entities

Health Plans
Health Care Providers
Health Care Clearinghouses