Here are some important Medical billing terms and explanations.
Referral
The Primary care physicians UPIN number needs to be added whenever a specialist receives a patient only then will the Insurance pay. In this situation when the family doctor cannot treat the patient since he is not qualified in any particular field then he would recommend the patient to go to a specialist for example Cardiologist, whenever the PCP sends the patient to a specialist then he would need to give a corresponding referral to the patient so that the patient can then hand it over to the specialists office.
Release of Information (ROI):
Patient gives all the information regarding his/her insurance, employment details and residential information. This note is called ROI.
SKILLED NURSING FACILITY
An institution or a distinct part of an institution, which has in effect a transfer agreement with one or more hospitals and is primarily, engaged in providing inpatient skilled nursing care or rehabilitation services.
•Provides skilled nursing care, continuous 24-hour nursing service, and maintains daily medical records for each patient.
•It must be licensed under all applicable state and local laws.
•It must be approved for payment of Medicare benefits or be qualified to receive that approval if so requested.
•It does not include any home or facility used primarily for rest, educational care, treatment of mental or nervous disorders or a facility for the aged which furnishes primarily custodial care, including training in routines of daily living.
•Licensed institution primarily engaged in the provision of skilled nursing care.
UCR allowable charges
The amount the insurance company will pay for a given procedure calculated on the UCR (Usual, Customary, and Reasonable) basis; the lesser of either the provider’s Usual Charge for the given procedure or the Customary Charge for the area. In the above statement Usual is defined as follows: the average fee for a given procedure the provider submits to the insurance company. Customary is defined as follows: the average or the 90th percentile of the charge (depending on how it is stated in the insurance policy) for a given procedure submitted to the insurance company by all the physicians in a designated geographical region. Reasonable means the same as “allowed” charges or approved fee.
UCR approved fee
See UCR allowable charges.
UCR charges:
The insurance company’s “approved fee” for a given medical procedure determined by calculating the charge submitted using the Usual, Customary, and Reason able formula. Also called the UCR Payment or UCR Profile.
UCR policy (Usual, Customary, and Regional/Reasonable Policy):
A policy that uses the usual, customary, and reasonable average fee profiles to determine the “allow able” reimbursement for each procedure.
W9 Forms:
These are forms that are used by the Internal Revenue Service in the U.S.A, for maintaining the collections of the physicians therefore should the Insurance want proof of address, UPIN # etc they would normally ask for the W9 forms so that they could update their records.
Workers’ Compensation
An insurance pro gram mandated by federal/state governments that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders
