Hospital and Clinic Billing
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| Clean Claim | Will pass CWF edits, is processed electronically, and does not require further contact or evidence
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| Incomplete Claim | Claim missing required information
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| Invalid Claim | Claim contains complete and necessary information, but the information is illogical or incorrect
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| Unprocessable | A claim considered incomplete or invalid due to missing claim form data elements
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| Non-standard | A claim that has extraneous attachments in lieu of data entered correctly in the claim form
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| 1 calendar year | Deadline to file a Medicare claim for services
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| Code edits | Examine a record for the correct use of ICD-9-CM codes
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| Coverage edits | Examine the type of patient and the procedures performed to determine if the services were covered
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| Clinical edits | Examine the clinical consistency of procedural and diagnostic information to determine if it is clinically reasonable
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| NCCI | Medicare's National Correct Coding Initiative promotes correct coding methodologies and strives to eliminate improper coding.
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| Data Mailer | A system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account
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| Medicare Summary Notice (MSN) | A statement to the payee and/or beneficiary reflecting services received, charges submitted, charges allowed, amount for which the beneficiary is responsible, and the amount that was paid to the provider or beneficiary.
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| Itemized Statement | Provides a complete listing or detailed account of every service posted to a patient account to include the date of service, descrition of service, service code, charge amounts, and totals.
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| CMS 1500 form | the equivalent electronic transaction is the 5010A1, formerly the 837P
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| Field locators 1-17 | Provider and patient information
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| Field locator 38 | Responsible party name and address
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| Field locator 29 | Accident State
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| Field locators 18-28 | Condition codes
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| Field locators 35-36 | Occurance Span Codes and Dates
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| Field locator 67 | Principal Diagnosis Code
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| Field locator 69 | Admitting Diagnosis
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| Field locator 51 | Health Plan Identifier Number
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| Field locators 42-49 | Revenue descriptions, codes, and charges
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| Field locator 58 | Insured's name
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| $1216.00 per spell of illness | Part A current year inpatient deductible, days 1 through 60
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| $304.00 per day | Part A coinsurance, days 61 through 90
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| $608.00 per day | Part A lifetime reserve, days 91 through 150
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| $0 per benefit period | Part A SNF care, days 1 through 20
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| $152.00 per day | Part A SNF care, days 21 through 100
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| $0.00 | Part A, home health care
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| Coinsurance (20% Medicare-approved amount) | Part A, DME
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| $147.00 per year, then 20% of Medicare-approved amount | Part B, Medical and other services
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| First 3 pints per year, then 20% of the Medicare-approved amount | Part B, Blood
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| Diabetes Screening Test | 2 screening tests per year with pre-diagnosis, 1 screening per year if tested but not diagnosed
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| Health Maintenance Organization (HMO) | Members must generally get healthcare from providers in the plan's network
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| Preferred Provider Organization (PPO) | members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist
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| Private Fee-for-Service Plans | allow members to got to any provider that accepts the plan's terms. The private company decides how much it will pay and how much members pay for services
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| Special Needs Plans | limit all or most of their membership to people in some long term care facitities, and who are eligible for Medicare and Medicaid.
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| Medicare Medical Savings Accounts | there are two parts, one part is Medicare Advantage Plan with a high deductible and the other part is a Medical Savings Account into which Medicare deposits money that people cand use to pay healthcare costs
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| Condition Code 02 | Condition is Employment Related
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| Condition Code 21 | Billing for Denial
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| Condition Code 40 | Same Day Transfer
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| Field Locators 31-34 | Occurrence Codes and Dates
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| Occurrence Code 01 | Auto Accident
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| Occurrence Code 11 | Date of Onset of Symptoms/Illness
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| Occurrence Code 18 | Date of Patient/Beneficiary Retirement
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| Field Locators 39-41 | Value Codes and Amounts
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| Value Code 01 | Most Common Semi-Private Rate
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| Value Code 12 | Working Aged Beneficiary/Spouse with EGHP
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| Value Code 13 | ESRD Beneficiary in a Medicare Coordination Period with an EGHP
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| Rev Code 250 | Pharmacy
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| Rev Code 300 | Lab
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| Rev Code 450 | Emergency Room
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Created by:
DRangel78
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