Contract Maximum

    Some insurance companies have a maximum payable amount on certain illness. The amount payable on a patient’s policy based on his/her contract is called Contract maximum.

Fee Schedule

    The amount fixed by the insurance for each procedure is called Fee schedule.

Copay

This is not a coinsurance. Co-pay is usually used on a Doctor PPO where you pay the first $10.00 or $20.00 for a Doctor visit and the insurance company pays the rest. The amount that you Co-pay for a doctor’s visit does not reduce your deductible or coinsurance. Co-pays are also used with Prescription Drug cards.

Medical billing Claim Types

Paper, Electronic, Clean, Dingy, Dirty, Rejected, Incomplete, Invalid, Participating Provider, Unprocessed and Dropped.

Tracer

            An enquiry made to Insurance Company to locate the status of an insurance claim as a follow up for data that is missing.

Tickler File

            It is used to remind patient of the upcoming or missed appointment as well as to track submitted, pending or resubmitted insurance claims. It is also called suspense or follow-up file.

Dropped Claims

            These are the claims rejected by the Clearinghouse due to wrong details or lack of information checked during the Preliminary Screening.

Unprocessed Claims

          These are claims that are rejected by the Insurance Company normally as a result of Prepayment edit/Pre-audit respectively.

Participating Provider Claim

            Claim sent on behalf of participating provider for reimbursement. These are processed within approximately 14 days of receipt. Non-participating provider claims are processed within approximately 27 days of receipt.

What is Invalid Claims

           It is any claim that contains complete, necessary information but is

Illogical or incorrect (e.g. listing incorrect Provider # for a Referring Physician).

These are to be resubmitted.

What is Incomplete Claims

          It is any claim missing the required information. These need to be resubmitted.

What is Rejected Claims

         They are those that require investigation and need further clarification.

They may need to be resubmitted.

What is Dirty Claims

     These are claims submitted with error or those requiring manual processing for resolving problems or rejection or payment.

What is Dingy Claims

     It happens when the insurance cannot process a claim for a particular service or bill type. The claims are held until the necessary system changes are implanted to pay the claim correctly.

What is Electronic Claims

          This is submitted to the Insurance carrier via a CPU, tape disk, digital fax etc. Different Formats used for electronic claims are:

1. NSF {National Standard Format} –This is used by Govt. it is a rigid format with 320

Bytes.        

2. ANSI {American National Standard Institution} – This is used by the private Institution with 132 bytes, and it is flexible one unlike NSF.

What is Paper Claim

    Submitted on paper by Billing Office or Providers Office including optically scanned claims that are converted to electronic form by the Insurance Carrier.

The forms used are: HCFA 1500, HCFA 1450 or UB-92