Medical Coding & Billing L2

Insurance

A contract short between an insurance company and an individual or group. Also called a carrier or insurer.

Insured

An individual or group

Medical insurance

Also called health insurance or Healthcare coverage is a contract between an insurance company and the insured for medical benefits

Contract or policy

An agreement of certain injuries or illnesses the insurance carry will pay some or all of the medical bills of the insured. In exchange for this coverage, the insurance carrier collects payments from the insured.

Benefits

When an insurance carrier pays for medical treatment based on a policy

Reimbursement

The compensation or repayment for healthcare services.

First party

Is the patient, Or the person responsible for the patient’s health bill. In some cases, this may be the guarantor.

Second party

Is the Physician, clinic, or hospital. This group is often known as the provider because it provides the healthcare services.

third-party payer

An organization, other than the first party or the second party involved in financing of personal health services.

Participating providers

Physicians in are into contracts with specific companies.

Allowable charge

Is the maximum amount and insurance company will pay for a specific service. When us subscriber sees a non-participating provider sometimes insurance companies will pay minimal benefits.

Deductible

The amount of money and individual must pay before the insurance benefits begin payment.

Copayment

Is a flat amount of money paid by the patient for prescription drugs or office visits to a doctor.

Explanation of benefits, EOB

A document that explains how much the insurance company paid and how much is this loud.

Pre-authorization

The insurance company requires notification before surgery, certain test, or various treatments are performed. The insurance company must be contacted even in an emergency.

Visitation limits

A set number of visits to specialist that a patient can make, or the number of special treatments a patient can have.

CMS – 1500

The standard Claim form used to request payment for services rendered by the healthcare provider

CPT

This manual contains codes that describe the procedures and services performed by the provider for outpatient services

HCPCS

Is the manual in which codes include drugs, Durable medical equipment, ambulance, services, and prosthetic procedures

ICD – 10 – CM

A coding system, a valid code may be between three and seven characters with a decimal after the third character.

Encounter form

When an insurance company pays for medical services, it reimburses either the the insured or the provider.

Claim form

A form that contains the most common codes performed by the doctor.