Medicare only. Medicare is not going to pay. Patient signs notice that they will pay if Medicare doesn’t pay

The amount an insurance company will pay to reimburse a healthcare service or procedure. The patient will typically pay the balance if there is any remainder.

The process by which a patient or provider attempts to persuade an insurance payer to pay for more (or, in certain cases, pay for any) of a medical claim. The appeal on a claim only occurs after a claim has either been denied or rejected (See “Rejected Claim” and “Denied Claim”).

This is a form signed by patient at the time of service at providers office which is more specifically related to personal injiury protection (PIP) which assigns the payment/benefit to the provider especially in arbitration. This is a requirement for arbitration.

Blue Cross Blue Shield is a federation of 38 health insurance companies in the U.S. (some of which are non-profit companies) that offer health insurance options to eligible persons in their area. Blue Cross Blue Shield offers healthcare plans to over 100 million people in the U.S.

Fees for visits, procedures and incidentals expected to be paid either by insurance or the patient

When an insurance company receives a claim, they go over the procedure codes and charges. They determine whether or not they will pay on each individual code, and how much. This is called the claims adjudication process.

A claim received by an insurance payer that is free from errors and processed is a timely manner. Clean claims are a huge boon to providers, as they reduce turnaround time for the reimbursement process and lower the need for time-consuming appeals processes. Many providers send their claims to third parties, like clearinghouses (See “Clearinghouse”), that specialize in creating clean claims.

A third-party organization in the billing process, and separate from the healthcare provider and the insurance payer. Clearinghouses review, edit, and format claims before sending them to insurance payers. This process is sometimes called “scrubbing.”

A type of insurance arrangement between the payer and the patient that divides the payment for medical services by percentage. While this is sometimes used synonymously with a co-pay, the arrangements are different: While a co-pay is a fixed amount the patient owes, in a co-insurance, the patient owes a fixed percentage of the bill. These percentages are always listed with the payer’s percentage first (eg a 70-30 co-insurance).

This refers to a binding agreement between a provider, patient, and insurance company wherein the provider agrees to charges that it will write off on behalf of the patient. Contractual adjustments may occur when there is a discrepancy between what a provider charges for healthcare services and what an insurance company has decided to pay for that service.

A patient’s co-pay is the amount that must be paid to a provider before they receive any treatment or services. Co-pays are separate from a deductible, and will vary depending on a person’s insurance plan.

Date services rendered

The amount a patient must pay before an insurance carrier starts their healthcare coverage. Deductibles range in price according to terms set in a person’s health plan.

This is a form signed by patient at the time of service at providers office which is more specifically related to commercial litigation claims and authorizes provider to appeal on behalf of patient. It is considered a limited power of attorney, the scope of which is limited to pursuing medical bills for that provider only.

Applies to uninsured patients

This refers to medical implements that can be reused such as stretchers, wheelchairs, canes, crutches, and bedpans.

Submission of electronic claims

EFTs offer an efficient, secure process for electronically depositing claims payments into a particular bank account. Some of the benefits of EFT in payment posting include -

• Faster payments as compared to paper checks
• Secure and confidential deposits of claims payments
• Reduced handling time by staff members and paper usage
• Payments can be easily verified by matching them to ERAs

EMR is a digitized medical record for a patient managed by a provider onsite. EMRs may also be referred to as electronic health records (EHRs).

It is a form of electronic communication which is HIPAA-compliant and contains claims payment information. With the help of ERAs, you can replace the paper-based Explanation of Benefits (EOB) statement. Some other benefits of ERA in payment posting include -

• Depending on the AR software, one can post payments without any manual intervention
• ERA is available for all types of benefit plans
• Separate ERA files can be received for the same TIN (tax identification number) and can be grouped by billing address
• Printable versions of ERAs make it easier to submit COB (coordination of benefits) claims

A document attached to a processed medical claim wherein the insurance company explains the services they will cover for a patient’s healthcare treatments. EOBs may also explain what is wrong with a claim if it’s denied.

A document that outlines the costs associated for each medical service designated by a CPT code.

Percentage based off the fee schedule percent of Medicare (ex. 300) to bring uninsured patient price down to 125% of Medicare. It is illegal to charge anyone less than Medicare, always to clinic.

Pronounced HICK-fah. Managed Care The preferred term is now Centers for Medicare & Medicaid Services–CMS, an agency of the US Dept of HHS that administers Medicare, the federal part of Medicaid and oversees Medicare's health financing; HCFA establishes standards for medical providers that require compliance to meet certification requirements. See CMS, JCAHO, Medicaid, Medicare. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

HIPAA was a law passed in 1996 with an aim to improve the scope of healthcare services and establish regulations for securing healthcare records from unwanted parties.

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Doctor explaining why he had to perform that service

A noninvasive diagnostic technique that produces computerized images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body induced by the application of radio waves

A trained person who assists women during childbirth. Many midwives also provide prenatal care for pregnant women, birth education for women and their partners, and care for mothers and newborn babies after the birth. Depending on local law, midwives may deliver babies in the mother's home, in a birthing center or clinic, or in a hospital. Most midwives specialize in normal, uncomplicated deliveries, referring women with health problems that could require hospitalization during birth to a hospital-based obstetrician. Others work with physicians as part of a team. Legal qualifications required to practice midwifery differ among the US states and various countries. https://www.medicinenet.com/script/main/art.asp?articlekey=4384

Not covered for medical necessity

The New York State Insurance Fund (NYSIF) was established in 1914 as part of the original enactment of the New York State Workers' Compensation Law. NYSIF's mission is to guarantee the availability of workers' compensation insurance at the lowest possible cost to New York employers and to provide timely, appropriate indemnity and medical payments to injured workers, while maintaining a solvent fund. Since inception, NYSIF has fulfilled the dual roles for which it was created: to compete with other carriers to ensure a fair market place and to be a guaranteed source of coverage for employers who cannot secure coverage elsewhere. https://ww3.nysif.com/Home/FooterPages/Column1/AboutNYSIF

Doctors' record of surgical services rendered

This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.

Personal injury protection (PIP) is an extension of car insurance available in some U.S. states that covers medical expenses and, in some cases, lost wages and other damages. PIP is sometimes referred to as "no-fault" coverage, because the statutes enacting it are generally known as no-fault laws, and PIP is designed to be paid without regard to "fault," or more properly, legal liability. That is, even if the person seeking PIP coverage caused the accident, they are entitled to make a claim under the PIP portion of their policy. "No-Fault" does not mean that insurance premium of the person making the claim will not increase. Typically a PIP claim is made by the insured driver to their own insurance company, however, there are several exceptions that allow persons who have been injured in an accident to make a PIP claim if they do not own a vehicle. The particular state law and policy language of the insurer should be reviewed to see what exceptions exist in that state.

Practice Insight is now a part of eSolutions! Learn more. Far more than a clearinghouse, EDIinsight® from Practice Insight® improves the entire billing and collections process, from EDI submissions to workflow management https://www.practiceinsight.net/

Set of processes leading up to the day of visit

Refers to medical records

The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.

A superbill is an itemized form, used by healthcare providers in the United States, which details services provided to a patient. It is the main data source for creation of a healthcare claim, which will be submitted to payers (insurances, funds, programs) for reimbursement. en.wikipedia.org/wiki/Superbill

The Coding Network, L.L.C. was established in 1995 on the concept that accurate professional and facility coding is mission-critical in today’s healthcare providers’ revenue cycle. Accurate coding is pivotal to improving reimbursement and is an essential component of compliance. The company’s founders and owners, Mark Babst and Neal Green, have a combined 70+ years of experience in the medical coding and billing environment. After very successful careers in academic and private medical practice and hospital management experience and 19 years of successfully providing coding and billing services to prestigious university medical centers via their prior company, they created The Coding Network to respond to the expanding demand for the accurate subspecialty coding required by Federal and state compliance regulations. https://codingnetwork.com/

Workers' compensation is paid by an employer when an employee becomes ill or injured while performing routine job duties. Most states have laws requiring that companies provide worker’s compensation.

This term refers to the discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. The write-off amount may be categorized as “not covered” amounts for billing purposes.