Insurance 101

2. Medicare fee schedule used to price physician services
6. Monetary amount that the member must pay before the insurance company will begin paying for their claims
10. Paid claim that was reversed for various reasons
13. Services performed by a MD/DO that are paid at a 16% reduction
17. Individual that provides medical care to a patient
18. Modifier 26
21. Contracted amount that a provider agrees to when signing a contract with the insurance company
22. Claim rejected for payment but has not yet gone through Check Run

1. Series of numbers unique to each member
3. Billing Provider ID begins with a "G"
4. Website used to view DLP
5. 2 digit code used to determine facility or non-facility pricing in MPFS
7. Name of the process that happens weekly where payment is sent out to the provider
8. Percentage that the member is responsible for each of their claims
9. Modifier TC
11. 5 Digit code that describes a service performed
12. CPT Code Range 700010-79999
14. Set dollar amount that a member pays alongside the insurance company
15. First action that needs to be done prior to processing a claim
16. Meaning of the first digit in the TOB 131
19. Billing Provider ID begins with an "F"
20. Claim held by the system for manual review
23. 99213 belongs to this category