Claims: Paper Claims – Electronic Claims – Clean Claims – Dingy Claims – Dirty Claims – Rejected Claims – Incomplete Claims – Invalid Claims – Participating Provider Claims – Unprocessed Claims – Dropped Claims
Paper Claims: It is one that is submitted on paper by the Billing Office or Providers Office including optically scanned claims that are converted to electronic form by insurance carriers.
The forms which are used for Paper Claim Processing are HCFA 1500 HCFA 1450 or UB-92.
Electronic Claims: It is one that is submitted to the insurance carrier via a CPU, tape diskette, digital fax etc., Different formats used for Electronic Claims are
a) NSF (National Standard Format)
It is a format used by the Government
It is a rigid format with 320 bytes.
b) ANSI (American National Standard Institution)
It is a format used by Private institutions with 132 bytes and it is a flexible one unlike NSF
Tickler File: It is used to remind patients of upcoming or missed appointments as well as to track submitted pending or resubmitted insurance claims. It is also called suspense or follow-up file.
Tracer: An inquiry made to an insurance company to locate the status of an insurance claim as a follow-up for something that is missing is called a tracer.
Payments: Deductible – Explanation of Benefits (EOB) – Bundled Payment – Transaction Control Number (TCN) – Rejection & Reviews – Out of Pocket Expenses.
Deductible: The amount of expense an insured must first incur before insurance begins payment for covered services.
Explanation of Benefits (EOB): After an insurance carrier processed a claim, and the claim is paid, a document known as an Explanation of Benefits is usually issued to the Provider who receives along with a payment check and to the Insured, if the benefits have been assigned. If the claim has not been assigned, payment goes to the patient and the physician may have a difficult time obtaining this payment.
In General EOB is also called as Statement of Benefits; Notice of Payment; EOB is called with different names by different Insurance; Medicare Remittance Advice (Medicare); Provider Payment Advisory (Blue Shield); Medex Detailed Advisory (Medex); Statement of Account (Tufts); Practitioner Remittance Advice (Medicaid while Primary); Practitioner Crossover Remittance Advice (Medicaid secondary); Explanation of Payment (Pilgrim Health).
Bundled Payment: A single comprehensive payment for a group of related services.
For example, 94760 (NONINVASIVE PULSE OXIMETRY, SINGLE DETERMINATION) – 94761 (NONINVASIVE PULSE OXIMETRY, MULTIPLE). In this case, if both the procedures are billed, insurance will pay for 94762 and will deny both 94760 & 94761 as already included in 94762.
Transaction Control Number (TCN): It is a number automated by the system while automatic crossover. If a claim is resubmitted then we need to provide the old TCN and the insurance will again provide a new TCN for the resubmitted claim. Normally, it has to be resubmitted within 2 weeks.
Out of Pocket Expense: Out of Pocket Expense normally refers to the payment made by the insured. Normally it refers to Both Copay and Deductibles.
Medicare: Medicare EOB – Payment Floor – Waiver of Liability – Crossover – Freelook (Medigap) – Development letter.
Medicare EOB: Medicare used to mail Remittance Advice (RA) to providers and the patient receives a Beneficiary RA. RA has been replaced by Medicare Remittance Advice also called the Medicare Summary Notice. Electronic Claim sending offices receive Electronic Remittance Advice (ERA), The ERA post payments automatically.
Payment Floor: The timeframe established for carrier payment of Medicare Part B claims. As of October 1,1993, electronically submitted claims will be paid 14 days after the date of receipt, while paper claims will be paid 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services.
ABN (Advance Beneficiary Notice) (Waiver of Liability): A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the Patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice.
Crossover: A situation whereby gaps in coverage for the medical expenses for a Medicare Beneficiary are forwarded by the Medicare contractor to the Patient’s medigap insurer for payment. Medigap crossovers only occur if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating medicare provider. Crossover takes place only in case of Medicare, Medicaid and Medigap Plans.
Freelook (Medigap): A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.
Development Letter: A notice from Medicare that a claim submitted by a provider organization cannot be processed without additional information/documentation. The letter identifies the additional information needed and the date by which the information must be received by Medicare.
Paper Claims: It is one that is submitted on paper by the Billing Office or Providers Office including optically scanned claims that are converted to electronic form by insurance carriers.
The forms which are used for Paper Claim Processing are HCFA 1500 HCFA 1450 or UB-92.
Electronic Claims: It is one that is submitted to the insurance carrier via a CPU, tape diskette, digital fax etc., Different formats used for Electronic Claims are
a) NSF (National Standard Format)
It is a format used by the Government
It is a rigid format with 320 bytes.
b) ANSI (American National Standard Institution)
It is a format used by Private institutions with 132 bytes and it is a flexible one unlike NSF
Tickler File: It is used to remind patients of upcoming or missed appointments as well as to track submitted pending or resubmitted insurance claims. It is also called suspense or follow-up file.
Tracer: An inquiry made to an insurance company to locate the status of an insurance claim as a follow-up for something that is missing is called a tracer.
Payments: Deductible – Explanation of Benefits (EOB) – Bundled Payment – Transaction Control Number (TCN) – Rejection & Reviews – Out of Pocket Expenses.
Deductible: The amount of expense an insured must first incur before insurance begins payment for covered services.
Explanation of Benefits (EOB): After an insurance carrier processed a claim, and the claim is paid, a document known as an Explanation of Benefits is usually issued to the Provider who receives along with a payment check and to the Insured, if the benefits have been assigned. If the claim has not been assigned, payment goes to the patient and the physician may have a difficult time obtaining this payment.
In General EOB is also called as Statement of Benefits; Notice of Payment; EOB is called with different names by different Insurance; Medicare Remittance Advice (Medicare); Provider Payment Advisory (Blue Shield); Medex Detailed Advisory (Medex); Statement of Account (Tufts); Practitioner Remittance Advice (Medicaid while Primary); Practitioner Crossover Remittance Advice (Medicaid secondary); Explanation of Payment (Pilgrim Health).
Bundled Payment: A single comprehensive payment for a group of related services.
For example, 94760 (NONINVASIVE PULSE OXIMETRY, SINGLE DETERMINATION) – 94761 (NONINVASIVE PULSE OXIMETRY, MULTIPLE). In this case, if both the procedures are billed, insurance will pay for 94762 and will deny both 94760 & 94761 as already included in 94762.
Transaction Control Number (TCN): It is a number automated by the system while automatic crossover. If a claim is resubmitted then we need to provide the old TCN and the insurance will again provide a new TCN for the resubmitted claim. Normally, it has to be resubmitted within 2 weeks.
Out of Pocket Expense: Out of Pocket Expense normally refers to the payment made by the insured. Normally it refers to Both Copay and Deductibles.
Medicare: Medicare EOB – Payment Floor – Waiver of Liability – Crossover – Freelook (Medigap) – Development letter.
Medicare EOB: Medicare used to mail Remittance Advice (RA) to providers and the patient receives a Beneficiary RA. RA has been replaced by Medicare Remittance Advice also called the Medicare Summary Notice. Electronic Claim sending offices receive Electronic Remittance Advice (ERA), The ERA post payments automatically.
Payment Floor: The timeframe established for carrier payment of Medicare Part B claims. As of October 1,1993, electronically submitted claims will be paid 14 days after the date of receipt, while paper claims will be paid 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services.
ABN (Advance Beneficiary Notice) (Waiver of Liability): A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the Patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice.
Crossover: A situation whereby gaps in coverage for the medical expenses for a Medicare Beneficiary are forwarded by the Medicare contractor to the Patient’s medigap insurer for payment. Medigap crossovers only occur if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating medicare provider. Crossover takes place only in case of Medicare, Medicaid and Medigap Plans.
Freelook (Medigap): A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.
Development Letter: A notice from Medicare that a claim submitted by a provider organization cannot be processed without additional information/documentation. The letter identifies the additional information needed and the date by which the information must be received by Medicare.
