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Mod 5 Ch 15

Ch 15 Medical Insurance

EDI Electronic Data Interchange Involving the computerized transfer of health care information between 2 parties for specific purposes.
NPI National Provider Number # assigned to Providers by CMS for submitting insurance claims.
Supporting Claim Documentation Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim.
Past Filing Limits Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected.
Medicare Federal Health Insurance program for people over age 65.
Medicare Part A Hospital Insurance that is automatic if you receive Soc Sec benefits.
Medicare Part B Fee-for-service, optional program that requires insured to pay income-based premiums.
Medicare Part C Medicare Advantage Managed Care
Medicare Part D Prescription Drug Coverage (limited)
WC Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness.
Tri-Care (formerly CHAMPUS) Government insurance program for active duty and retired military personnel.
CMS Centers for Medicare and Medicaid Services
ABN Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare.
Out-of-Pocket Expenses Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers.
Primary Payer 1st payer, usually responsible for more money or higher charge
Secondary Payer MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose).
Physician Fee Schedule The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient.
VOB Verification of (Insurance) Benefits Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt.
Pre-Authorization Contacting the insurance company to obtain permission for a procedure.
COB Coordination of Benefits Determining the Primary / Secondary insurances
Co-Pay Fixed $ amount that the patient pays
Co-Insurance Fixed % that the patient pays
Deductible Monetary amount patient must pay before insurance kicks in.
CMS-1500 Uniform billing format used for medical claims.
Medicaid MCD - Health benefit program for low-income patients. ALWAYS billed 2nd.
PCP Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations.
CHAMPVA Insurance through government for disabled veterans.
Created by: vanstellee



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