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Claims

Horizontales
____ sort a procedure into a category for system processing. This allows the appropriate cost-sharing to be applied.
____ codes are Two-digit, alphanumerical codes added to the end of CPT or HCPCS codes to provide further information.
after the claim has been submitted, UPMC Health Plan has 30 days in which to ____ the claim for payment.
Claims are generated by a ____ billing an insurance company for payment for services rendered to a patient.
Whenever a claim needs adjusted, please be sure to tell the member it is being sent for “____” instead of for “adjustment”
____ codes are three-to-five-digit, alphanumerical codes detailing the diagnosis or rationale for each procedure.
___ codes can tell us the reason a claim was adjusted.
____ codes are five-digit, numerical-only codes to report medical procedures and services to entities such as physicians, health insurance companies and accreditation organizations.
Sometimes, CPT codes route into the incorrect Benefit Category. If that occurs, we can submit for a “____ ____ Inquiry” via CCD.
____ Claims are claims for facility fees. These will only be charged for services performed at hospitals, outpatient clinics, and skilled nursing facilities.
Which denial happens when the provider submits the same service twice. The member will still receive an EOB for the claim we denied, even if it was paid elsewhere?
____ Claims are claims for provider services. These are your most common claims that include PCP/Specialist visits, Lab Services, Physical Therapy, et cetera.
____ Billing occurs when a provider attempts to collect payment for the difference between the amount billed and the amount allowed by the insurance.
An ____ Stay is when a patient goes to an Emergency Room, but after being looked at and treated, the doctor determines it is medically unsafe to let the patient leave without further monitoring the condition.
Verticales
____ codes are five-digit, alphanumerical health care procedural codes based on the American Medical Association’s Current Procedural Terminology.
No ____ Act bans surprise billing and balance billing for emergency services and for services performed by a nonparticipating provider on behalf of a participating provider
Where can claim images be found to determine if the correct place of service was applied.
___ codes are linked according to the plan the member is enrolled in, the network, and the provider that is submitted on a claim. This will determine the benefit and pricing amount applied.
Whenever UPMC receives a claim, it must go through ____ ____. If a claim does not show a billed amount or member’s share, that indicates to us that the claim has not gone through yet.
Claims typically consist of several aspects including: Provider, Facility, Cost-sharing, and ___.
Some screenings ca be billed as ____ or diagnostic, depending whether the test came back negative or positive.
Diagnosis Codes are important because some procedures are only ____ if performed for the correct diagnosis.
____ codes are four-digit, numerical-only codes for billing institutional claims that indicate what type of services were performed and where.
Medical ____ is the practice of assigning procedures and diagnoses to alphanumerical data for billing purposes. In retail, we simply need to read these codes to understand coverages and cost-sharing for claims processing