The statement that the hospital receives, usually for payment, from your insurance company after your medical services have been processed. A type of insurance plan that only requires patients to consult providers (doctors and hospitals) who have a contract with the managed care company, except in the case of medical emergencies or emergency care when the patient is outside the plan`s service area. Maximum lifetime health insurance in your plan is the total amount that the insurance company pays for the entire duration of your insurance under that plan. Once you reach this amount, your plan will no longer pay your medical expenses. Revenue Cycle Management (RCM): A comprehensive RCM is a financial process that manages vendor credentials and registration, eligibility and benefits verification, claims processing, payment viewing, and revenue generation. RCM and Optometric Billing Services work with your Medical Information Centre to streamline and simplify administrative and clinical functions so you can capture, manage and collect patient services revenue. Arbitration: The process of deciding medical claims once the claim has reached the payer to determine whether to accept, deny or reject the claim. The process includes the payer`s assessment of the medical claim, the decision on whether the claim is valid and compliant, and how much the payer reimburses the provider for the claim. Starting at 1. In January 2021, healthcare providers and medical bill billers will need to use the new E/M codes for 99202-99215 (99201 was removed in 2021) and select the code based on MDM level or total time. For more information, refer to the American Medical Association® (AMA) CPT E/M Code and Guideline Changes and Table 2 of the CPT®® E/M decision-making level to determine the appropriate code for ambulatory or ambulatory emergency services.

Medical Group Any partnership, association or group of licensed health care providers who collaborate in medical practice. The standard claim form used by institutional providers such as hospitals to bill insurance companies for medical services. A portion of your bill that your provider must write off due to billing agreements with your insurance company. ICD-10 codes indicate why an invoiced procedure was performed. Together, the insurance company`s ICD-10 and CPT codes indicate the medical services actually provided, allowing the insurance company to determine the fees allowed and payable for these procedures. An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals. The process by which a patient or provider tries to convince an insurance payer to pay more (or in some cases for all) of a medical claim. An appeal of a claim is only made after a claim has been denied or denied (see „Denied Application” and „Rejected Application”). Medical devices that can be used multiple times, or special devices ordered by your doctor, usually for home use. Wellness Program A health management program that includes the components of disease prevention, medical self-care and health promotion. A network of health care providers who provide patients with coverage for medical services exclusively within that network.

We`ll cover this type of insurance in more detail in later videos. Military service insurance. ChampVA shares the costs of certain medically necessary procedures and supplies with eligible beneficiaries. ChampVA does not have a network of healthcare providers, so eligible members can visit most authorized providers. Prior authorization Formal authorization obtained by the insurance company prior to the provision of medical services. Medicare sets an annual limit for certain medical services. If a patient exceeds this threshold, known as the usage limit, they may not be eligible for Medicare coverage for this procedure. Claims Cleanup: A process to ensure that medical claims are clean and error-free before they are submitted.

Medically necessary Refers to services or supplies that are necessary to properly treat a particular medical condition. Services or deliveries that are not considered medically necessary by the insurance company may be refused. Electronic Data Interchange (EDI): A connection between your billing system and the insurance company and how billing transfers claim data to different insurance payers. Credentials: Sometimes called accreditation for medical providers. This is the process of capturing and authenticating (verifying) a doctor`s qualifications (employment and educational history). Certification ensures that providers have the necessary licenses, certifications and skills to care for patients. Accreditation of an insurance plan is often referred to as „entry into insurance boards.” Sometimes an insurance company may decline a service because of its classification as experimental or research. This means that the drugs or services are not yet widely recognized in the medical community as acceptable treatments for the disease or approved by the FDA. Elective Refers to medical procedures that are not immediately necessary, usually procedures that can be planned in advance. Code assigned to medical and surgical procedures and treatments. Secondary insurance Secondary coverage, usually due to coverage provided by someone else`s health insurance (such as a spouse), provides for reimbursement of medical expenses after the available coverage has been purchased by the primary plan. Secondary insurance may also pay for medical services if primary insurance denies coverage.

Recommendation A doctor`s prescription for services or consultations to be provided by another provider, usually a specialist. This video defines the most important terms and concepts in the billing process, so you can jump straight to more complex topics. Electronic Claim A digital representation of a medical bill created by a health care provider or the provider`s billing office for submission via telecommunications to a health insurance payer. A medicinal product, device, diagnostic procedure, treatment, preventive measure or similar medical intervention that has not yet been shown to be medically safe and/or effective. Services that are considered testing services are generally not covered by health insurance. If offered as part of a clinical research study, the study itself may cover the costs. If necessary, check with your insurance plan or study team to see if coverage is available for experimental or experimental treatments. Pre-existing conditions A health problem or medical problem that you already have before purchasing insurance. Some health insurers may not pay for health problems you already have for a predetermined period of time. Utilization Management Assessment of medical needs, effectiveness and/or adequacy of health services and treatment plans. Research to evaluate the safety and/or effectiveness of a treatment, diagnostic procedure, preventive measure or similar medical intervention by testing the intervention in patients in a clinical setting. Participation in clinical research is voluntary.