View the patient relationship codes which depicts who the insurance listed belongs to. Item 1a - Enter the patient's Medicare Health Insurance Claim Number . insurers) with whom CMS has a payer-to-payer coordination of benefits relationship. .. Reminder: Do not report ICDCM codes for claims with dates of service prior to . Item 25 - Enter the provider of service or supplier Federal Tax ID (Employer. Provide the code which indicates the relationship of each .. Guides to Federal Employees Health Benefits . claims for health benefits services or supplies.
OPM OPM can order correction of an administrative error after reviewing evidence that it would be against equity and good conscience not to do so. Impaired Relationship OPM may order a change in your enrollment from a particular HMO when you can show that you cannot receive adequate medical care because you or a family member and your HMO's health care providers have a seriously impaired relationship. BoxWashington, DC Processing Elections Generally, the responsibility for processing health benefits actions is divided between the personnel and payroll offices.
References in this section to Standard Forms and apply to the August and June editions respectively. Prompt Action on Elections Your personnel and payroll offices must process your election within one week after their receipt.
This is very important to protect your eligibility for benefits especially when you are enrolling in an HMOto keep health plan carriers fully informed of the status of its enrollments, and to avoid retroactive adjustments in withholding and contributions. Each of these forms contains instructions explaining its use. Your employing office will use this space to give information needed to support any action that is not apparent from the completed form.
For example, to show that as a new employee, you are enrolling on a timely basis, your employing office will note "Appointed date ", or "Converted to eligible type of appointment date ".
It should not include information that is not relevant to your health benefits, such as the reason for separation, or title and grade of your position. Special entries in the Remarks section are required if you are a temporary continuation of coverage TCC enrollee or a temporary employee eligible under 5 U.
The SF may be in either paper or electronic format. Whenever the use of the SF is discussed in this section, it refers to either the paper or electronic format. If you are enrolling in an employee organization plan, your employing office must accept your enrollment but also advise you that you must become a member of the organization, if you are not already a member; obtain a medical certificate from you if you have listed a child age 26 or over as a family member.
Your employing office will record its determination of capability for self-support in the Remarks section on all copies of the form e. If coverage is approved for a limited period of time, your employing office will prepare a follow-up notice to remind you in writing, at least 60 days before the certificate expires, that it must be renewed.
If your employing office doesn't approve coverage, it will remove the child's name from the listing of family members; if you are a temporary employee enrolling under 5 U.
These entries may be made by rubber stamp, overprint, or facsimile signature; file a copy on the right or permanent side of the Official Personnel Folder or its equivalent ; send the new carrier and payroll office copies of SF to the payroll office for transmission to the carrier and for posting to the payroll records, respectively.
If it prefers, your employing office may send all copies except the enrollee copy to the payroll office for its action and later return of the Official Personnel Folder copy for filing.
It will discard the old carrier copy if it is a new enrollment; give you the enrollee copy, so you can use it as proof of enrollment until the carrier sends you an identification card. Processing an Election not to Enroll Your employing office will process your election not to enroll in the FEHB Program by following the applicable instructions under " Employing Office Review of SF ," except that the carrier copies should be destroyed.
Processing an Election Change Your employing office will process your election change as outlined in " Employing Office Review of SF " and take these additional steps: It will discard the old carrier copy; if you are changing plans, your employing office will use the new carrier copy of SF to notify the gaining carrier, and the old carrier copy to notify the losing carrier; if you are changing plans, the correct transmittal document report number must be entered on each carrier's copy.
SF Your employing office uses the Notice of Change in Health Benefits Enrollment form SF to record certain changes in an enrollment not requiring your signature. It is used for an enrollment termination but not a cancellationreinstatement, change in payroll office, and a name change.
In case of an enrollment termination, the back of the original enrollee copy of the SF serves as your official notice of the day extension of coverage and conversion right. The back of the form also explains other rights you may have continuation of enrollment on transfer, retirement, death, or entitlement to compensation under the Federal Employees' Compensation law. Temporary Employee's Change in Employment Status If your employment status changes from a temporary employee enrolled under 5 U.
The SF documents the change in premium withholding and when your enrollment begins to count toward the requirement for continuation after retirement. You may change your enrollment if you wish. Your employing office prepares a Notice of Change in Health Benefits Enrollment SF and notes in the Remarks section the reason and date of the change e.
It will note in the Remarks section the event permitting reinstatement e. Your employing office will send you the enrollee copy, file a copy on the right side of the Official Personnel Folder, and send the carrier and payroll office copies to the payroll office for transmission to the carrier and posting to the payroll records, respectively. Transfer Between Payroll Offices Continued Coverage Your enrollment and coverage continue without change when you transfer from one payroll office to another without a break in service of more than 3 days.
Your employing office will promptly take action to transfer your enrollment.
Eligibility for Health Benefits
See " When You Transfer to a Different Payroll Office Daily Proration Rule " for information on each payroll office's responsibility for withholdings and contributions. Gaining Employing Office Actions Your gaining employing office will perform a record check on SF 75 before you enter on duty to establish your current enrollment status, enrollment code number, and Social Security number.
When you enter on duty, your employing office will: It will inform you of any opportunities you may have at that time to change your enrollment e. It will keep a file copy for your Official Personnel Folder, and send the carrier and payroll office copies to the payroll office for transmission to the carrier and posting to the payroll records, respectively; verify the transfer-in action on the basis of the health benefits documents located in your Official Personnel Folder.
If the action was correct, it will file a copy of SF on the right side of the Official Personnel Folder or its equivalent.
If the action was not correct, it will correct the error. If the losing office erroneously terminated your enrollment, the gaining employing office will use part D to show a reinstatement of the enrollment rather than part C to show a transfer in.
Mass Transfers When you are part of a group of 25 or more employees enrolled in the same plan to be transferred on the same day from one payroll office to another payroll office, your employing office doesn't need to prepare a separate transfer-in Notice of Change in Health Benefits Enrollment SF for each of you. The gaining employing office may make a list of all the employees involved in the transfer and attach several copies to only one SF documenting the mass transfer in.
It will post the change in payroll office number on the latest SF in each of your Official Personnel Folders so that the payroll office number is up to date.
The gaining employing office will prepare the list in three columns, with column 1 for the employee's name, column 2 for the Social Security Number, and column 3 for the enrollment code number. Voiding Health Benefits Actions When Voiding is Appropriate Voiding is appropriate only when an incorrect health benefits action must be withdrawn and your enrollment status must revert to what it was before the incorrect action was taken.
Voiding has the effect of removing the incorrect action as though it never occurred. Procedure To void an action, your employing office marks "VOID" in bold letters on the Official Personnel Folder and payroll office copies of the form on which the incorrect action was taken either the SF or SFand explains the action in the Remarks section.
A guide to important medical billing terms
Additional remarks are required when an erroneous enrollment is voided. If your employing office had sent the carrier's copy of the form, it will send the voided payroll office copy to the carrier with the next regular transmittal. If the action being voided is a change in plan, it will send a copy of the voided SF to both the old and new carrier. If a copy had not been sent to the carrier, it will destroy all but one copy to be retained in your OPF. Significant errors include errors in your name, enrollment code, Social Security number, the effective date of a health benefits action, or a listing of family members when there are none.
The form may show only the specific item s being corrected, or your employing office may substitute another complete corrected form for the one previously submitted. Your employing office will send the corrected form to your carrier with the next regular transmittal. If the erroneous information was sent to both the old and the new carriers, each will be sent a corrected form. Your payroll office cannot accumulate health benefits forms for longer than one week.
Verification Before transmitting a copy of a health benefits form to a carrier, your payroll office must verify that the payroll action required by the form can be taken e. A copy of the form can be released to the carrier before payroll action is completed to adjust the health benefits control or to note the individual pay record. Preparing Transmittal Report Your payroll office will prepare an original and two copies of the transmittal report.
It will hold the second copy until the carrier returns a certified copy. The carrier code is the first two characters of the carrier's enrollment code number. Appeal occurs when a patient or a provider tries to convince an insurance company to pay for healthcare after it has decided not to cover costs for someone on a claim. Medical billing specialists deal with appeals after a claim has been denied or rejected by an insurance company. Applied to Deductible ATD: This term refers to the amount of money a patient owes a provider that goes to paying their yearly deductible.
Assignment of Benefits AOB: This term refers to insurance payments made directly to a healthcare provider for medical services received by the patient. Assignment of benefits occurs after a claim has been successfully processed with an insurance company. ASP is a digital network that allows healthcare providers to access quality medical billing software and technologies without needing to purchase and maintain it themselves.
Providers who use ASP typically pay a monthly fee to the company that maintains the billing software.
A patient may be denied coverage if they see a provider for a service that needed authorization without first consulting the insurance company. Blue Cross Blue Shield: Blue Cross Blue Shield is a federation of 38 health insurance companies in the U. Blue Cross Blue Shield offers healthcare plans to over million people in the U. A fixed payment that a patient makes to a health insurance company or provider to recoup costs incurred from various healthcare services. A capitation is different from a deductible or co-pay.
This type of care is administered at reduced or zero cost to patients who cannot afford healthcare. Providers may offer charity care at their discretion. This refers to a medical claim filed with a health insurance company that is free of errors and processed in a timely manner. Some providers may send claims to organizations that specialize in producing clean claims, like clearinghouses. Clearinghouses are facilities that review and correct medical claims as necessary before sending them to insurance companies for final processing.
The CMS is the federal entity that manages and administers healthcare coverage through Medicare and Medicaid. CMS coordinates with providers and enrollees to provide healthcare to over million Americans. The CMS is a paper medical claim form used for transmitting claims based on coverage by Medicare and Medicaid plans.
Commercial insurance providers often require that providers use CMS forms to process their own paper claims. Medical billing specialists must be familiar with many code sets in order to perform their job duties.
A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled. The percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in a health plan.
Co-insurance percentages vary depending on the health plan. This refers to the ratio of payments received relative to the total amount owed to providers. This refers to a binding agree between a provider, patient, and insurance company wherein the provider agrees to charges that it will write off on behalf of the patient.
Contractual adjustments may occur when there is a discrepancy between what a provider charges for healthcare services and what an insurance company has decided to pay for that service. Coordination of Benefits COB: COB occurs when a patient is covered by more than one insurance plan. In this situation one insurance company will become the primary carrier and all other companies will be considered secondary and tertiary carriers that may cover costs left after the primary carrier has paid.
CPT codes represent treatments and procedures performed by a physician in a 5-digit format.
Medical billing specialists will enter CPT codes into claims so insurance companies understand the nature of healthcare a patient received with a provider. The application process for a provider to coordinate with an insurance company.
Once providers have become credentialed with an insurance company, they have the opportunity to work with that company in providing affordable healthcare to patients. When claim information is sent from a primary insurance carrier to a secondary insurance carrier, or vice versa.
The date when a provider performed healthcare services and procedures.
Medical Billing and Coding Online
A document that summarizes the services, treatments, payments, and charges that a patient received on a given day. The amount a patient must pay before an insurance carrier starts their healthcare coverage. This refers to medical implements that can be reused such as stretchers, wheelchairs, canes, crutches, and bedpans.
Date of Birth DOB: The exact date a patient was born. Downcoding occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed coded medical services and so they reduce or remove those codes. Downcoding usually reduces the cost of a claim. A formal request typically submitted by an insurance carrier to determine if other health coverage exists for a patient.
The abbreviation for diagnosis codes, also known as ICD-9 codes. The format of electronic claims must adhere to medical billing regulations set forth by the federal government. EMR is a digitized medical record for a patient managed by a provider onsite. A person covered by a health insurance plan. Explanation of Benefits EOB: The digital version of EOB, which specifies the details of payments made on a claim either by an insurance company or required by the patient.
This act established guidelines and requirements for health and life insurance policies including appeals and disclosure of grievances. F Fee for Service: This refers to a type of health insurance wherein the provider is paid for every service they perform. People with fee-for-service plans typically can choose whatever hospitals and physicians they want to receive care in exchange for higher deductibles and co-pays. A document that outlines the costs associated for each medical service designated by a CPT code.
Whoever owes the healthcare provider money has financial responsibility for the services rendered. Insurance companies or patients themselves may be financially responsible for the costs associated with care, and these responsibilities are typically outlined in a healthcare plan contract.
The name for Medicare representatives who process Medicare claims. A table or list provided by an insurance carrier that explains what prescription drugs are covered under their health plans. Providers, patients, or insurance companies may be found fraudulent if they are deliberately achieving their ends through misrepresentation, dishonesty, and general illegal activity.
Medical billing specialists who deliberately enter incorrect or misleading information on claims may be charged with fraud. A plan provided by an employer to provide healthcare options to a large group of employees. The name of the group, insurance carrier, or insurance plan that covers a patient. A number given to a patient by their insurance carrier that identifies the group or plan under which they are covered. The party paying for an insurance plan who is not the patient.
H Healthcare Financing Administration: The former name for what is now the CMS. HCPCS is a three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system. This is insurance offered to a group or an individual to cover costs associated with medical care and treatment. These are the entities that offer healthcare services to patients, including hospitals, physicians, and private clinics, hospices, nursing homes, and other healthcare facilities.
The major healthcare legislation passed in designed to make healthcare accessible and less expensive for more Americans. The unique number ascribed to an individual to identify them as a beneficiary of Medicare.
HIPAA was a law passed in with an aim to improve the scope of healthcare services and establish regulations for securing healthcare records from unwanted parties. HMOs are networks of healthcare providers that offer healthcare plans to people for medical services exclusively in their network.
This refers to medical care and treatment for persons who are terminally ill. ICD codes are estimated to be mandatory in the American healthcare system by October A fee for nursing services a patient is charged during the course of receiving healthcare. A type of health insurance plan whereby a patient can receive care with any provider in exchange for higher deductibles and co-pays.
Indemnity is also known as fee-for-service insurance. Inpatient care occurs when a person has a stay at a healthcare facility for more than 24 hours.
Intensive care is the unit of a hospital reserved for patients that need immediate treatment and close monitoring by healthcare professionals for serious illnesses, conditions, and injuries. MACs are contract with the federal government to process Medicare claims. Maximum Out of Pocket: The amount a patient is required to pay. After a patient reaches their maximum out of pocket, their healthcare costs should be covered by their plan. A medical billing specialist is responsible for using information regarding services and treatments performed by a healthcare provider to complete a claim for filing with an insurance company so the provider can be paid.