Medical Billing Information
Terms and Resources
This is a catch-all page for downloadable medical billing information, resources for your practice, and medical billing terms. It's a work in progress so we will continue to add to it.
ABN stands for Advanced Beneficiary Notification. This is a written notice given to Medicare beneficiaries that they must sign before providing an item or service that you expect Medicare will deny.
ANSI 4010 is the uniform file format to send and receive medical transactions. The format was mandated in 2008 as version 4 release 1, thus the name, 4010. ANSI stands for American National Standards Institute. It is an insurance committee that sets the standards for the electronic model of a paper transaction or form for North America. The primary standards for medical transactions are 837 for medical claims, 835 for medical claim payments, 270 eligibility inquiry and 271 eligibility response.
ANSI 5010 is the next iteration of ANSI 4010. It is designed to remove some of the confusion in the current format and will be implemented January 1, 2011.
An authorization is a request for treatment (an office visit, procedure, or surgery) made by a provider to an insurance company. The insurance company must approve the request before treatment is delivered otherwise, the practice will not be paid.
CMS Form 1500 is the medical billing term for the standard insurance form used to bill Medicare Part B and other carrier professional claims. It was formerly called HCFA Form 1500. Learn the most common reasons why paper hcfa claims get rejected.
COB or coordination of benefits is medical billing information that refers to how insurance coverage is applied when a patient has multiple insurance policies. Insurance coverage can be either primary (first position), secondary (second position), or tertiary(third position).
If an individual receives insurance benefits through their employer, his/her insurance will always be primary. If an individual has additional benefits through their spouse’s insurance, that will be considered secondary.
If a working Medicare beneficiary has his/her own employer insurance coverage, that coverage is automatically primary and Medicare is secondary.
If a non-working Medicare beneficiary has insurance coverage through their working spouse, that coverage is automatically primary and Medicare is secondary.
If a dependant child has coverage through both his father and his mother, the “birthday rule” applies. This means the insurance coverage of the parent whose birthday occurs first in the year is automatically primary. Remember this rule is not based on the parent’s age. The only exception is a court order for a specific parent to provide insurance coverage.
A crossover claim refers to a secondary claim that is processed or "crossed over" automatically when the primary Medicare claim is processed.
An electronic claim is the electronic version of a CMS-1500 form. It is also referred to as an 837 file.
EOB stands for Explanation of Benefits. This is a report from an insurance carrier advising the provider of the payment details of a submitted claim. Basically, it includes the date of service, procedure code, charge amount, allowed amount and/or contract write-off, patient coinsurance amount or deductible, and the payment amount. Reduced or zero payments are explained with reason codes.
ERA or electronic remittance advice is the electronic version of an Explanation of Benefits. It is also referred to as an 835 file.
ICD-9-CM stands for International Classification of Diseases (ICD) clinically modified (CM). It is the standardized means of tracking disease.
ICD-10-CM will replace ICD-9-CM effective October 1, 2013. For more medical billing and coding information, take a look at ICD-10 Myths & Facts.
Medicare participating vs. non-participating providers. Both PAR and Non-PAR providers must bill the claim to Medicare. A PAR provider must accept assignment, the check comes directly to the provider and the patient cannot be charged at the time of service except for the deductible. The Non-PAR provider can choose whether to accept assignment or not. By not accepting assignment, the Non-PAR provider can collect a slightly higher fee. Download Medicare PAR vs. Non-PAR Options to find out more details.
Medicare Consult Codes and Modifier AI. See details here.
A Medicare Secondary Reason Codes is required when submitting a Medicare secondary claim. It tells Medicare the reason why they are the secondary insurance. The codes are:
- Black Lung (41)
- Disabled Beneficiary Under Age 65 with LGHP (43)
- End-Stage Renal Disease (13)
- No-Fault Insurance including Auto is Primary (14)
- Other Liability Insurance is Primary (47)
- Public Health Service or Other Federal Agency (16)
- Veterans’s Administration (42)
- Worker’s Compensation (15)
- Working Aged (12)
NPI stands for National Provider Identifier. It is the unique number used to identify a healthcare provider.
A Group NPI is assigned to an entity such as a medical practice or group practice that is incorporated. Individual providers work under the group. This NPI normally appears in Box 33 on the CMS-1500 form.
The place of service is the code that indicates where the service takes place. It appears in Box 24b of the CMS-1500 form.
RAC stands for Recovery Audit Contractor. It refers to a Medicare program started in 2003 that uses auditors to identify and correct improper Medicare payments paid to fee-for-service healthcare providers.
A superbill or fee slip is a charge form used for each office visit. It includes the CPT and diagnoses codes used in the practice.
UPIN refers to the Medicare identifier used to identify Medicare physicians prior to the implementation of the NPI.
It is our goal to save you time so I hope this medical billing information reference page will prove useful to you.
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