Lump Sum Purchase of DME, Prosthetics, Orthotics

For injection codes with more than one possible TOS designation, use the following guidelines when assigning the TOS:
When the choice is P or 1,

• Use TOS P if the drug is administered through durable medical equipment (DME); or
• Use TOS 1 if the drug is administered in the office.

What is CMS 1500 Claim Form?

Claim Form CMS  :

In the 1960s there were a number of different claim forms and coding systems required by third-party payers to communicate information regarding procedures and services to agencies concerned with insurance claims. However, there was no standardized form for physicians and other health care providers to report health care services. Therefore, the American Medical Association (AMA) embraced an assignment in the 1980s to work with the Centers for Medicare & Medicaid Services (CMS; formerly known as HCFA), and many other payer organizations through a group called the Uniform Claim Form Task Force to standardize and promote the use of a universal health claim form.

Although many providers now submit electronic claims, many of their software/hardware systems depend on the existing 1500 Claim Form in its current image. Minor changes have been made to the form in order to accommodate the National Provider Identifier (NPI) as well as other identifiers.

The 1500 Health Insurance Claim Form answers the needs of many health payers. It is the basic paper claim form prescribed by many health plans for claims submitted by physicians and suppliers, and in some cases, for ambulance services.

Insurance Types:{medical billing}

ü Federal Insurance

ü Private Insurance

ü Liability Insurance

Federal Insurance:

1. Medicare

  * Part A (Hospital Insurance)

  * Part B (Supplementary Medical Insurance)

  * Part C (Medicare + Choice)

  * Part D ( Prescription Drug)

2. Medicaid

3. CHAMPUS (Civilian Health And Medical Program for Uniform Services)

4. CHAMPVA (Civilian Health And Medical Program of Department of Veteran Services)

Private Insurance:

1.Medigap

2.IHP

3.GHP

Liability Insurance:

   * General Liability ( fire, house owner’s Risk, etc.,)

  * Auto Insurance

  * Workers Compensation Liability

Billing Terminalogy....

Medical Billing Terminalogy

1.Participating Providers

2.Non – Participating Providers

3.Capitation

4.Fee For Service (FFS)

5.Referral

6.Referral Authorization Number (RAN)

7.Pre-Authorization or Pre-Certification

8.Pre-Determination

9.Waiver of Liability

10.ABN ( Advanced Beneficiary Notice)

11.PayBack or Refund

12.Offset

13. Pre-Existing Condition

14.Waiting Period

15.COB ( Coordination of Benefits)

16.Deductible

17.Copay

18.Co-Insurance

19.Out of Pocket Expenses

20.Stop Loss Clause

21.Contract Maximum

22.Providers Identification Number

 

Types Of Insurance (Medical Billing)

Insurance Types

1 Federal Insurance

2 Private Insurance   3 Liability Insurance

lFederal Insurance:

l1. Medicare

l  * Part A (Hospital Insurance)

l  * Part B (Supplementary Medical Insurance)

l  * Part C (Medicare + Choice)

l  * Part D ( Prescription Drug)

l2. Medicaid

l3. CHAMPUS (Civilian Health And Medical Program for Uniform 

Services)

 

l4. CHAMPVA (Civilian Health And Medical Program of   

 Department of Veteran  Affairs)

 

lPrivate Insurance:

lMedigap

lIHP

lGHP

lLiability Insurance:

l* General Liability ( fire, house owner’s Risk, etc.,)

l* Auto Insurance

l* Workers Compensation