Medical Billing Question and Answer - Terms

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Medical billing process and concept question

 Difference between inclusive and bundled

AS far as I know both are same. Different insurance use different terms.

Billed Charges

The total charges made by a provider for all services and supplies provided to the member. 


The sharing of allowable charges for covered services. The sharing is expressed as a pair of percentages, a Plan percentage that we pay, and a member percentage that they pay. Once the member has met any applicable deductible amount, the member’s percentage will be applied to the allowable charges for covered services to determine the member’s financial responsibility. The Plan’s percentage will be applied to the allowable charges for covered services to determine the benefits provided.

Difference between authorization and pre-authorization in medical billing?

Both are same however pre-authorization is the one we need to get before providing the service

Coordination of Benefits (COB)

Determining primary/secondary/tertiary liability between various healthcare benefit programs and paying benefits in accordance with established guidelines when members are eligible for benefits under more than one healthcare benefits program.

Copayment (Co-pay) 

That portion of charges for covered services, usually expressed as a dollar amount that must be paid by the member and usually collected by a physician at the time of service.

Covered Services

Those medically necessary healthcare services and supplies for which benefits are specified under a member contract/certificate.

Current Procedural Terminology (Procedure )

System of terminology and coding developed by the American Medical Association that is used for describing, coding and reporting medical services and procedures.


A specific amount of Covered Services, usually expressed in dollars, that must be incurred by the member before Blue Cross is obligated to member to assume financial responsibility for all or part of the remaining Covered Services under a member contract/certificate.

Electronic Funds Transfer (EFT)

Allows payment to be sent directly to iLinkBLUE enrolled providers’ checking or savings accounts. 

With EFT, providers can view their Weekly Provider Payment Registers in iLinkBLUE and they will not receive a Payment Register by mail.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) 

The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), otherwise known as HIPAA, was enacted as a broad congressional attempt at incremental healthcare reform. The “Administrative Simplification” section of that law requires the United States Department of Health and Human Services (DHHS) to develop standards and requirements for maintaining and transmitting health information.

Health Reimbursement Arrangement (HRA) An employer-funded plan that reimburses employees for Qualified Medical Expenses (QMEs); an HRA is funded solely by the employer. Reimbursements for medical expenses, up to a maximum dol ar amount for a coverage period, are not included in an employee’s income. Unused funds can be rolled over annually but are owned by the employer and thus are not portable when the employee leaves the employer’s company. Health Savings Account (HSA) A tax-exempt trust or custodial account established exclusively for the purpose of paying qualified healthcare expenses of the account beneficiary who, for the months of which contributions are made to an HSA, is covered under a high-deductible plan. An HSA is employee-owned but can be funded by the employer and/or the employee. Unused funds are owned by the employee and thus are portable when the employee leaves the employer’s company. 

Difference between 11 & 12 place of service
11 - office (Provider location) visit and 12 - Patient home

Difference between appeal limit and filing limit+medical billing
Filing limit is first time filing and appeal limit is time frame to appeal the claim after denial or low payment.

Difference between billed amount and allowed amount
Difference between fee and allowable in anesthesia billing
Billed amount - What provider billed the insurance.
Allowed amount - What the insurance agree to pay

Participating Plan

A licensee participating in Blue Bank ownership and governance. Also means: A Licensee in whose service area a national account has employee and/or retiree locations, but in which the national account headquarters is not located unless otherwise agreed in accordance with National Account Program policies and provisions.

Professional Allowance/Allowable Charge

 The lesser of the submitted charge or the amount established by the Plan as the maximum amount allowed for physician services covered under the terms of the member contract/certificate. 


A licensed or accredited hospital, medical supply or service vendor, or individual that provides medical care to a member.

Difference between claim rejection and denial+medical billing

We can use both word for same meaning. However rejection can't be appeal and denial can be appeal.


Employees or individuals and their enrolled dependents covered under a subscriber contract/  certificate who are entitled to receive healthcare benefits as defined in and pursuant to a subscriber contract/certificate. 

Difference between medicare part a and part b
If we need to say in one word
Part A covers hospital and facility billing
Part b covers provider billing

Difference between co 16 and co 50
CO - 16 - Lack of information - check additional denial
CO - 50 - check the CPT and DX combination.

Difference between write off and adjustments in medical billing
Both are same.

Difference between claim and remittance
Claim - Form to use file the information and send it to insurance CMS 1500
Remittance - EOB

Re-submission Codes for CMS 1500

We have to update the Original reference number/Claim number to Correcting a paper HCFA 1500 in BOX 22. Enter "7" for Replace billing code while submitting electronic claim in Re submission block in PMS. 

CMS 1500 field 22 is used to list the original reference number for resubmitted/corrected claim. When resubmitting a claim, enter the appropriate code.

6 Corrected Claim
7 Replacement of prior claim
8 Void/cancel of prior claim

Re submission means the code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim. 

Billing question

can a insurance company deny a medical claim due to missing cpt modifier
Ans :Yes they can.

Solution: We need to file appropriate modifier to get paid.

can you use a v04.81 as a primary dx for 99213
Ans : No.

Note : It should be used for vaccination and inoculation.

can the hospital bill 99213 pos 23
Ans : No.

Note : Place of service 23 could bill only in Emergency room – Hospital.

Can 99213 be billed with 96372 

Ans : No. It will not be paid.
Solution : We have to file with 20553 or any other injection code along with modifier 25 for 99213
Note : 90772 changed to 96372 for 2009

Can 99213 and 99223 billed together

Ans: Two E&M Can not be bill together.

Solution: If the two codes billed, then we need to Write/off for the unpaid CPT. Consultations, critical care, procedures, diagnostic services, and any other non-E/M service cannot be billed as shared visits. Which E/M services can be billed as a shared visit? Most common: New patient visits, established patient visits (follow-up visits), initial hospital visits, subsequent hospital visits, prolonged services, emergency department E/M services.

Can 99291 be billed on a UB 04
Ans : Yes. You can billed on UB 04 form
Solution : UB04 form should be use for facility code 14, 24......

If critical care codes 99291 and 99292 services billed in conjunction with admit type 1. Hospitals are required to use HCPCS code 99291 to report outpatient encounters in which critical care services are furnished. The hospital is required to use HCPCS code 99291 in place of, but not in addition to, a code for a medical visit or for an emergency department service.

Can I bill both CPT codes 85025 and CPT code 36415

Ans : No.

Note : If you have billed CPT 36415 with 85025 they will not be separately reimbursed.

Can 99395 be reimbursed

Ans : 99395 will not be separately reimbursed when submitted with CPT 90772. If the Preventative Maintenance code is billed in any other combination if E&M codes, it will not be payable.

Note :99395 when used for EPSDT services, will be reimbursed at 60% of the Medicare non-facility rate when the recipient is agae 21 or older.
99395 when used not for EPSDT, will be reimbursed at 74% of the Medicare non-facility rate when the recipeint is age 21 or older.

Insurance denial question and answer

Can we bill the patient for a denied pre-existing condition claim

Ans : Yes. But make sure that the patient has secondary coverage; we need to send the entire bill to secondary along with the primary denial. Some carriers may be pay and some may not at that time you can bill the patient.

Note : Pre-existing condition refers to the terms and conditions entered in to between the carrier and the patients/subscribers before the beginning of the contract.  The rejection will usually say that the claim is being denied due to the pre-existing condition.  It would not specify what exactly; the condition is.  So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything.

Claim denial types
There is no particular type in denial however below are the common reason
Claim might be denied for incorrect coding information.
Claim might be denied for incorrect provider information.
Claim might be denied for incorrect coverage information
Claim might be denied for lack of information

 Claim denials by managed care organization plague long-term care providers
Should be file the claim to patient HMO plan

Claim denials for maximum unites per visit
Check your units of the CPT

Claim denied as inclusive with the primary procedure
Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.

Claim denied as services not provided or authorized by designated
File the claim along with appropriate authorization#. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.

Claim denied because of incorrect medical coding
Should be file the claim with correct diagnosis (Dx) and CPT

Claim denied because this injury is the liability of the no-fault carrier.
Should be file the claim to patient auto-insurance.

Claim denied by medicaid because primary insurance changed
File the claim to patient primary insurance. If we don’t have patient primary insurance details needs to call the patient and get the insurance information.

Claim denied by medicare for code co-16 what do i do to get this paid?
      We will receive this denial if we have filed the claim with insufficient information. This code co-16 must have additional denials information that informs us what kind of information is missing with claim.

Claim denied due to pre-existing condition
Patient needs to update the medical (medical history) document to insurance and provider also update the medical document to insurance.

Claim denied for CLIA certification#
Should be file the claim with clia certification number. We must file the lab code with clia number.

Claim denied for coordination of benefits
Patient needs to update the COB information to insurance. If patient has more than one insurance, patient need to call the insurance and inform that which insurance is primary and secondary for patient. Patient only can update the COB information to insurance.

Claim denied for maximum benefits reached

File the claim to secondary along with denied EOB. If patient do not have another insurance we can bill the patient.

Claim denied for valid referral

Should be file the claim with valid referral. If we do not have valid referral number, we can request the same from referring doctor and refile the claim with valid referral.

Claim denied no billing code.
Kindly call the insurance and get the reason behind the denials and get the correct CPT

Denied benefits is not covered by the patient's plan.

 We can bill the patient.

Denied insurance claims due to invalid CPT code
     Should be file the claim with valid CPT. For example medicare and HMO plans (Humana, freedom health, AVMED, universal, wellcare, Polk county, PUP,) does not cover the consultation code (99241 to 99245 and 99251 to 99255).

Claim denied reason dates of service over one year from process date are not payable.
    Should be file the claim with in timely filing limit. If you received the denial even filed the claim with in TFL we can appeal the claim with TFL proof. All insurances has separate filing limit.

Claim denial codes and what action needs to be taken
Each denied claim should have valid reason behind the claim denial and needs to take appropriate action from the denials

Claim denial vs claim rejection
Claim denied by insurance and claim rejected by clearing house OR EDI department

Claim denials bundling inclusive
Needs to differentiate the service by using appropriate modifier and Dx else taken write-off the claim balance

 Claim denied primary paid in full
Need to write-off the claim balance.

Cross Over Claims 

Medicaid reimburses providers for the coinsurance and deductible amount on Medicare claims for Medicaid recipients who are dual eligible for Medicare and Medicaid. The amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed to Medicaid.

User Question and answer

What is the difference between Eligibility Date and Effective Date?

Eligibility date is Generally DOS and effective date is policy start date.

how often should you post electronic funds transfers?
In General post it on daily basis.

I have few Medicare timely filing denials. Medicare does not accept timely filing appeals. Can we bill the patient for 20% of total charge amount?

NO - Its not a legally accepted.

can any tell me what is co share

Its a Patient share of any service or secondary insurance balance

Can you write off a patient's deductible, copay or coinsurance balance due?

Yes, but should be a valid reason. We should not write off to attract the patients.


Chitra said...

Please help me in getting the claim status for no fault claims

Denial reasons & the questions to be asked with the adjustor

Rajesh said...

Can we bill intial evalution and therapy services on a same day to medicaid?

KELLI M said...


Anonymous said...

Which CPT code should you bill for if the encounter form holds a 99212office visit and a 93005 ECG? 99212 pays more according to OPPS.

Anonymous said...

i need guidance on correcting denial remark code co8.

Anonymous said...

Can you bill a 99214 for cupping, or any acupuncture services? Or is a 99214 just to be billed as an office visit and not used for services a medical plan that does not cover....

Anonymous said...

If I billed a 90801 in June 2011 when can I bill it again?

Anonymous said...

Can you write off a patient's deductible, copay or coinsurance balance due?

Anonymous said...

Im fresh out of school and there isnt anything like tryin to bill clia waived test cpt code 80101 can someone help me i know what code im using and how many units but whats a good way to come up with the totals.

Unknown said...

can any tell me what is co share

Anonymous said...

humana is denying cpt 99218 but not 99220 what do i use in place of 99218 to get claim paid, they paid for 99220

Chanuka Pamidu said...

I have few Medicare timely filing denials. Medicare does not accept timely filing appeals. Can we bill the patient for 20% of total charge amount ?

Chanuka Pamidu said...

I have few Medicare timely filing denials. Medicare does not accept timely filing appeals. Can we bill the patient for 20% of total charge amount?

Unknown said...

I am pondering opening a professional Nurse consultation service. This service would evaluate residence for potential health issues, that complicate various disease problems. Once an evaluation would be completed and suggestions made the report would go to the physician and insurance company (if premium deduction is encouraged after items are corrected). How could I bill for this? Is there a code for home health evaluations or consultations?

Anonymous said...

why would you need a authorization if you are a hospitalist for cpt 99219

Anonymous said...

What is the billing address in tn

Anonymous said...

Can someone help me with procedure code 99183? Provider has billed 6 in a one month period. Medicare denied stating procedure inconsistent with modifier or requires modifier missing. Tried modifier 26, did not work.

Anonymous said...

What is the difference between Eligibility Date and Effective Date?

Anonymous said...

how often should you post electronic funds transfers?

Anonymous said...

Can a mobile IDTF that rent space at a doctor office bill services that were rendered in a doctor office on UB04 Form?

Anonymous said...


Unknown said...

A corrected claim denied as duplicate because it was submitted incorrectly and is processing . In our system, correcting a claim creates a new claim. Can the previous payment from the original claim be moved to the corrected claim PRIOR to a new EOB or proper reprocessing from the corrected claim?

CindyJ said...

I bill for NEMT. WE bill for multiple trips for the same member in one day. What modifier combination should be used for this situation? Our procedure code is A0080. Any help with modifier combinations for NEMT procedure code A0080 would be appreciated.

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