Claims Terminology

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Across
  1. 1. Healthcare Common Procedure Coding System - alpha-numeric codes that represent items, supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes.
  2. 3. Money that an individual is required to pay for services, after a deductible has been met. This amount is often specified by a percentage.
  3. 6. An agreed to and accepted amount most providers in a geographic region charge for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
  4. 8. An insurance provision designed to ensure that reimbursement for members with more than one health care policy does not exceed 100% of allowed covered expenses.
  5. 9. Standard claim form used to submit outpatient or individual provider-based services. (Such as outpatient therapy or a psychiatrist who assesses a patient in a medical bed at a hospital.) Requires a CPT Code, Location Code and ICD-10.
  6. 10. Explanation of Payment - a written document generally sent to the provider and includes the check. Note: For reimbursement policies the EOP is sent to the member/subscriber.
  7. 11. The amount an individual must pay for health care expenses before the plan will begin sharing the cost of covered benefits. Often, insurance plans have an annual deductible amount.
  8. 13. Two-digit code that identifies where the services took place. Required for all levels of care.
  9. 14. Current Procedural Terminology - a code set that defines what a provider or insured will bill for. The CPT-4 (current version is 4) code book establishes standards and translates services into 5-digit codes which are used to complete the service codes section of a claim form. These codes are the primary codes which must be used to submit outpatient service claims.
Down
  1. 2. Center for Medicare and Medicaid Services. This organization defines the standard forms and codes used for billing across insurance carriers.
  2. 4. International Classification of Diseases Codes which identify the patient’s diagnosis. This information is required for all levels of care.
  3. 5. of Benefits Written permission given to a provider (usually) allowing them to bill and receive payment on behalf of the patient. This is box 13 on a CMS 1500 form which requires signature from the member or “signature on file” validating that the member has agreed to allow them to bill and receive the payments directly.
  4. 6. Standard claims form used by facilities and hospitals to submit charges, using HCPCS codes.
  5. 7. Code Service codes that are also used by facilities/hospitals. Must be submitted for higher levels of care on a UB04.
  6. 8. A predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. This amount is often specified as a dollar amount, not as a percentage.
  7. 10. Explanation of Benefits - a written document explaining the final status of processed claims. This document is most commonly sent to the member, or to the subscriber for the policy (if not the member).
  8. 12. Type of Service - two-digit code that identifies the form of treatment being received (detox, mental health, substance abuse).
  9. 14. A request from an individual or their provider/facility to the insurance company for the payment for services obtained from a health care professional.