Administrative cost are reduced.
Payment of the claim is denied.
They pay a fine to the health plan.
Patient's coverage is cancelled.
Explanation of benefits
Health insurance claim
Payment information about a claim.
Provider qualifications and responsibilities.
Detected errors and omissions from claims.
Documentation of medical necessity.
Create medical service bureaus.
Limit lifetime maximum amounts of coverage.
Provide lost wages for injured workers.
Implement prepaid health plan services.
Wagner National Health Act
Hill - Burton Act
Committee on the cost of Medical Care ( CCMC )
Tatical Committe on Medical Care
Contact the patient via telephon to alert him about the request.
Let the patient's physician handle the situation personally.
Make a copy of the record an mail it to the insurance company.
Require a signed patient authorization from the insurance company.
Billing for services that were not furnished and misrepresenting diafnoses to justify payment.
Charging excessive fees for services, equipment, or supplies provided by the physician.
Submitting claims for services that are not medically necessary to treat patient's condition.
Violating participating provider agreements with insurance companies and government programs.
Falsifying certifications of medical necessity, plans of treatment, and medical records to justify payment.
Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third party payer.
Soliciting, offering, or receiving a kickback for procedures and/or services provided to patients in the physician's office.
Unbundling codes: that is, reporting multiple CPT codes on a claim to increase reimbursement from a payer.
Billed as an additional surgical procedure.
Coded for office data capture purposes only.
Included at part of the original procedure.
Not reported on the CMS-1500 or UB-04 .
DRG payment - diagnosis -related group system that reimburses hospitals for inpatient stays.
A patients stay was prolonged due to medical or pychological complications.
Charges submitted to the payer are lower than the provider's normal fee (eg., -22 added to code).
Surgery defined as an inpatient procedure was performed while tha patient was in the hospital.
Surgery typically categorized as an office procedure was performed in the hosptital outpatient setting.
No distinction is made between the plans
The plan thast has been in place longest
Who is older
Who is younger
Whose birthday occurs first in the year.
Whose birthday occurs last in the year.
Contains the dashes associated with the SSN.
Contains the ID Number without dashes.
Is left blank, because SSN are private.
Can contain spaces or dashes when the number is entered.
MM DD YYYY OR MM DD YY
MM-DD-YYYY OR MM-DD-YY
MM/DD/YYYY OR MM/DD/YY
MMDDYYYY OR MMDDYY
Either an X or a checkmark
05 05 YYYY
05 10 YYYY
The word NONE
Nothing (leave the block blank)
No punctuation or space
The provider's SSN
Complete and submit two CMS-1500 claims.
Mail the remittance advice to the payer.
Send the secondary CMS-1500, but not the primary claim.
Submit just one CMS-1500 to the payer.
Employer Identification Number (EIN)
National Provider's Number (NPI)
Provider's Identification Number (PIN)
Social Security Number (SSN)