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Medical Insurance Terms
HCFA 100 form
The standardized Medicare claim form required by Medicare for submission of claims to a Medicare carrier and most payors when a provider submits claims for reimbursement. This form is used by health care providers in MD office based settings, and must be used for Medicare MNT claims. NSF/ANSI837 is the electronic claims form that may be used in place of the HCFA 1500 paper claims form. An ANSI-accredited group that defines standards for the cross-platform exchange of information within a health care organization. HL7 is responsible for specifying the Level Seven OSI standards for the health industry. The X12 275 transaction will probably incorporate the HL7 CRU message to transmit claim attachments as part of a future HIPAA claim attachments standard. The HL7 Attachment SIG is responsible for the HL7 portion of this standard.
How Medical billing works?
In the , health-care providers are required by law to charge the same fee to any patient to whom they provide a specific service. Let s say a primary-care doctor sees an established patient who is sick and codes the visit as a "99213" - a Level Three sick visit. The doctor charges the standard fee for this service: for example, $67.
Now, a self-pay (uninsured) patient will be charged $67 and will probably pay $67. If the patient has managed care insurance, then the doctor will be paid the fee he agreed to accept in his managed care contract - probably $50 to $55 - $10 from the patient s co-pay and the rest from the HMO. If the patient has Medicare or Medicaid, then the doctor gets the Government-determined amount for that service in that county. The last time I looked, and it happened to be in Dutchess County, NY , Medicare paid $43.62 for a Level Three sick visit, and Medicaid paid $11 for the same service.
Rendering Provider
In case the primary care doctor believes that you need specialized care he refers you to a IPA. This IPA is called the Rendering provider and the referring one is referring provider.
Preferred Provider Organization (PPO)
An organization of hospitals and physicans who provide, for a set fee, services to insurance company clients. These providers are listed as preferred and the insured may select from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal copayment for each office visit or hospital stay. Contrast with Health Maintenance Organization. (LI,H)***
Secondary CoverFage Coverage which provides payment for charges n ot covered by the primary policy or plan.
Electronic Transmitter Identification Number (ETIN)
A unique number assigned to each transmitter and software developer by the IRS.
ISA - Interchange Control Header Purpose
To start and identify an interchange of zero or more functional groups and interchange-related control segments.
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