Coordination of Benefits (COB), How insurance companies decided which one pays first when a patient has more than one plan, Own Employer Rule, Your own job insurance pays before a spouse’s insurance, Birthday Rule, For dependents, the parent whose birthday comes first in the year provides primary insurance, Superbill / Electronic Encounter Form, A form listing diagnoses and procedures used for billing, CMS-1500 / 837P, Forms used to submit professional medical claims (paper and electronic), RBRVS, System used to determine how much providers get paid for services, Resource-Based Relative Value Scale, System used to determine provider payment based on resources used, Relative Value Units, Numbers that represent the value of medical services for payment, Geographic Practice Cost Index, Adjusts provider payment based on location, Clearinghouse, Company that checks claims for errors before sending them to insurance, Clean Claim, Claim with complete and correct information that can be processed quickly, Dirty Claim, Claim with missing or incorrect information that delays payment, Medical Necessity, Services must be reasonable and required for insurance to pay, E/M Codes, Codes used for office visits based on time and complexity, HCPCS Level II, Codes for medical supplies and non-physician services, American Medical Association, Organization that creates CPT codes, Centers for Disease Control, Organization that maintains ICD-10 codes and tracks diseases, Centers for Medicare and Medicaid Services, Government agency that manages Medicare and Medicaid, Prior Authorization, Approval needed from insurance before a service is performed, Advance Beneficiary Notice, Notice telling Medicare patients a service may not be covered, HIPAA Title I, Protects health insurance coverage, HIPAA Title II, Protects patient privacy and security, Treatment, Payment, Operations (TPO), Situations where patient information can be shared legally, HMO, Insurance plan requiring referrals and using a limited provider network, PPO, Insurance plan allowing more provider choice and usually no referral required, Electronic Remittance Advice, Electronic explanation of how a claim was paid, Remittance Advice, Statement explaining insurance payment decisions, Medical Claim, Request sent to insurance asking for payment, National Provider Identifier, Unique number that identifies a healthcare provider, Upcoding, Billing for a higher level service than what was actually done, Unbundling, Separating services that should be billed together to increase payment, Diagnostic Code / ICD-10 Code, Code explaining why the patient was seen, Procedural Code / CPT Code, Code explaining what service was performed, HCPCS Code, Codes for supplies, equipment, and certain services, Category 1 ICD-10 Code, First three characters showing general diagnosis category, Category 2 ICD-10 Code, Adds more detail to the diagnosis, Extension of ICD-10 Code, Adds extra information like encounter type, Clinical Modification, Changes made to codes for use in the United States, Not Otherwise Specified, Used when information is incomplete, Not Elsewhere Classified, Used when no specific code exists, Excludes 1, Codes that should never be used together, Excludes 2, Codes that can be used together if appropriate, Explanation of Payment, Document showing how insurance paid and what patient owes.

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