Glossary N - P

What is Non-Participating.



In this scenario then the AR needs to identify if out-of-network benefits would be given to a particular patient under this Insurance in some cases the Insurance does not pay for out of network benefits, whereas in other instances there is a penalty of low reimbursement rate, and a slower processing time. Therefore these considerations need to be looked at critically in order to effectively coordinate the collection level.


What is NPI?



The National Provider Identifier (NPI) is another key initiative, which will help in the prevention of fraud and abuse.

NPI is an industry wide unique identifier for providers and suppliers created under the authority of the Health Insurance Portability and Accountability Act of 1996.

CMS developed the NPI effective from 1st Jan 1997.

The NPI is a single block of 10 characters.

The one and only advantage of a NPI over PIN numbers are they are unique for all health plans. NPI are used in the administrative and financial transactions specified by HIPAA


Primary care physician



A Physician who is a member of a Medical group. In which the member has selected to provide health care service. A primary care physician is responsible for authorizing, coordinating and controlling the delivery of covered services to the member. He is also called as Gate Keeper.


Provider Identification Number



PIN is the individual provider number issued by the local Medicare carriers. This number helps the provider in receiving the reimbursement for claims filed to Medicare carrier. The format of PIN is unique and varies from carrier to carrier. If this number is not indicated on all Medicare carrier claims (paper/electronic) will result in a denial as “Unprocessable Claims”.


Unique Physician Identification Number



UPIN is a six digit numeric / alphanumeric number allotted to all Medicare Providers. UPIN is issued by HCFA. A UPIN is required if the service is requested by a referring physician or an ordering physician.


Pre-Admission Certification:



Before being admitted as inpatient in a hospital certain criteria are used to determine whether the inpatient care is necessary.


Pre-authorization:

Is when the Insurance needs to be contacted prior to rendering of any medical service. Some type of treatments which are of big dollar value for example Radiation Therapy (for cancer treatment) would be very expensive, therefore the carrier would request the doctors office to obtain previous approval from their Utilization Management department before treating any patient, in this way they could track their expenditure as well as keep track on all big dollar accounts. If the doctor's office fails to get this authorization then the claim would be denied.

Under Managed Care we have HMO's, PPO's, EPO's.


Pre-Existing Condition:

A health problem that existed or was treated before the date your insurance became effective. Most health insurance contracts have a pre existing condition clause that describes under what condition they will cover medical expense related to a pre-existing condition.


Provider Enrollment Forms

These forms would be given by the carrier which needs to be filled in correctly so that the Insurance could then update their records of who is the doctor/Provider his UPIN number his mailing address the location of his facility, and is he/she treating in more than one facility. All these details would be fed into their system to maintain accurate records.

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