Glossary - Payments

In Medical billing payment related terms are very important for follow up with insurances.

Payments


• Deductible
• Explanation of Benefits (EOB)
• Bundled Payment
• Transaction Control Number (TCN)
• Rejection & Reviews
• Out of Pocket Expenses


Deductible:


The amount of expense an insured must first incur before insurance begins payment for covered services.


Explanation of Benefits (EOB)


After an insurance carrier processed a claim, and the claim is paid, a document known as an Explanation of Benefits is usually issued to the Provider who receives along with a payment check and to the Insured, if the benefits have been assigned. If the claim has not been assigned, payment goes to the patient and the physician may have a difficult time obtaining this payment

In General EOB is also called as

Statement of Benefits
Notice of Payment

EOB is called with different names by different Insurances

Medicare Remittance Advice (Medicare)
Provider Payment Advisory (Blue Shield)
Medex Detailed Advisory (Medex)
Statement of Account (Tufts)
Practitioner Remittance Advice (Medicaid while Primary)
Practitioner Crossover Remittance Advice (Medicaid secondary)
Explanation of Payment (Pilgrim Health)


Bundled Payment:


A single comprehensive payment for a group of related services.
For example,
94760 (NONINVASIVE PULSE OXIMETRY,SINGLE DETERMINATION)94761 (NONINVASIVE PULSE OXIMETRY, MULTIPLE)
In this case, if both the procedures are billed, insurance will pay for 94762 and will deny both 94760 & 94761 as already included in 94762


Transaction Control Number (TCN)


It is a number automated by the system while automatic crossover. If a claim is resubmitted then we need to provide the old TCN and the insurance will again provide a new TCN for the resubmitted claim. Normally, it has to be resubmitted within 2 weeks.


Rejection/Reviews:


Basically, when a claim is submitted, there may be two types of response from the insurance.

a.Denial
b.Payment

Under Denial, it is categorized as Rejections and Reviews only for the purpose of billing office for further follow up.


Rejection:


When an insurance company denies a claim stating that info provided in the claim is not sufficient to process the claim, for which the patient or guarantor is responsible (which can be collected only from them) is called the “Rejection by Insurance”. Eg. Incorrect Ins ID#, Wrong Ins, etc.

Review:


When an insurance company denies a claim stating that it needs additional info for processing, which can be obtained from the Provider’s or billing office can be defined as “Review”. Wrong Procedure or Diag Code, Invalid or Incomplete info on claim etc are some of the examples for review.


Out of Pocket Expense:


Out of Pocket Expense normally refers to the payment made by the insured.
Normally it refers to Both copay and Deductibles.


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