Hi mam, good evening.

Thank you for giving opportunity to speak on my profile.

My name is ………….. & I Born and bought up in mumbai. & about my family there are 6 members in my
family, me my mother is homemaker, and my father is a government employee. I have three Siblings.
and about my Qualification, I am B.com graduate & I am having 4 Years of experience in medical billing
as AR & Current designation is Sr. AR

I started my carrier with Infix Jun 2018 later for better opp I switched Gebbs in jul 2019 and left sep
2021 as our process got ramp down.

Later i switched with Getix Health india From Nov 2021 To Nov 2023 & I joined this company in
pandemic it was WFH and later they started calling Office to Bangalore location & Due to banglore
expenses, I was not able to manage expenses, So i decided to switch, Later I came to know about Clinic
anywhere by my friend of friend, Heard about good growth of employee in this company &
Management is very good, so I applied here.

It was end to end process too

No process was available at that moment

I have worked on multi-specialty.

Pedorthic we use to receive claims for new born baby.

ESRD End-stage renal disease (ESRD) is the final, permanent stage of chronic
kidney disease. It's a terminal illness with a glomerular filtration rate of less
than 15 mL/min. Dialysis

My Target was 40 claims,

30 calling and 10 analysing and I use achieve my target and overachieve my target.

In which cases Medicare act as secondary payer?

Ans: MSP plan & Medicare secondary Payer.
No-Fault Insurance and Liability Insurance: When an individual has Medicare and met with
an accident or other situation where no-fault or liability insurance is involved. Then
Medicare is acting as Secondary and No-Fault insurance is primary.

RCM (Revenue Cycle Management) – It is a process of collecting money from patient and
insurance company for healthcare services provided to patient.
Steps of RCM-
1- Appointment- In this step patient will call the provider office and take the appointment for
treatment
2- Eligibility verification – In this step insurance eligibility will be check whether policy active
or not.
3- Authorization and referral- In this step authorization or referral will be obtained in
required.
4- Registration- This step patient information will be added in provider system like
demographic information and insurance policy information.
5- Encounter- In this step provider will provide the health related services to patient.
6- Medical Transcription – In this step Medical records will be document by using the
recording tape which provider used during providing the service to patient.
7- Medical Coding- In this step coding will be done after reviewing the Medical records.
8- Charge entry- In this step charges will be entered in billing software.
9- Billing – In this step billing team will bill the claim form to insurance.
10- Payment Posting- In this step posting will be done for claims for which we have received
response from insurance.
11- AR follow up- AR follow up will be done on denied claims and for claim for which we have
not received any response and it is more than 30 days.
12- Collection- In this step of RCM collection done.
13- Refund- In this step refund will be initiated for incorrect payment received from insurance.

14- New Patient: - Visiting the provider for the first time or after 36 months from the last visit.
15- Established Patient: - Visiting the provider within 36 months from last visit.
16- Inpatient services: - Patient who is taking the services for more than 24 hrs.
17- Outpatient services: - Patient Who is taking the services for less than 24 hrs.
18- Medicare Eligibility - Age above 65, ESRD ( End stage reneal disease), Permanent disability, Obama
rule ( if person is working in coal mines and suffering from black lungs is also eligible for Medicare)
Us Tax payers,
19- Medicaid:- If individual is below poverty line he/she will be eligible for Medicaid, Pregnant women,
Blind and deaf.
20- Medicaid Spend: If Due to medical expenses any individual become below poverty line he will be
eligible for Medicaid for that particular month which is known as Medicaid spend down.
21- We use W9 form to update the billing group information and pay to address.
22- LCD (Local coverage Determination ) :- It determines whether Dx ( Diagnosis ) and CPT combination
is valid or not.
23- NCD (National Coverage Determination ) : It determines whether procedure will get covered or not.
24- CLIA (Clinical Laboratory improvement amendment ) :- CLIA required only for Lab codes ( 8- Series
codes ). It is basically kind of certification provided by CMS to Labs to perform lab services after
checking the accuracy of test. There are some minor Lab codes which does not require CLIA
certification number and those tests are known as CLIA waved test. CLIA waved test can be billed
without CLIA number with QW modifier.
25- ABN ( Advance Beneficiary Notice ) : This only applicable for Medicare Traditional patients. When
provider feels that services provided to patient will get deny as non-covered. Provider takes
signature on ABN form in order to bill the balance to patient if Medicare denies the claim as non-
covered service.
26- AOB (Assignment of benefit) : It is a document signed by patient for provider to directly get paid
from insurance company for services provided to patient.
If AOB Not signed, then Insurance Will Pay to Patient and we will bill to patient &
 Also if non participating provider render services and patient has PPO type Plan which
cover Out of Network Benefits, in this case also patient receive payment.
27- ROI (Release of information) :- This approval from patient to provider to use patient personal
health related information for billing purpose.
28- COBRA (Consolidated Omnibus budget reconsilation act) – In this policy any individual will get
covered upto 18 months from unemployment date under group health insurance provided by
employer.
29- COB ( Co-ordination of benefit ) : It gives the sequencing to payers which insurance will act as
primary insurance if patient is having more than one insurance.
30- Medicare Advantage plan: - Medicare advantage plan also known as MCO ( Managed care
organization ) and Medicare Traditional will replaced by Medicare Advantage.
31- Medicare Supplemental Plan: - Medicare supplemental will always act as secondary insurance to
Medicare.
32- QMB (Qualified Medicare Beneficiary ) :- Medicare will be the primary insurance and Medicaid will
act as secondary to Medicaid and in this plan we cannot bill patient.
33- Cooling period- Cooling period is time Gap from Insurance Enrollment date to Effective date.

34- Claim Aging: - Claim aging determines the age of the claim from DOS to till today. There are aging
buckets like 30 days claim, 60 days claims, 180 days claims and 365+ days claims are known as Old
AR.
35- Waiting period- Waiting period is time during which insurance will not cover the pre-existing
services.
36- Premium- It is an amount which patient need to pay beginning of every year to continue the
insurance coverage.
37- Deductible- It is an fixed amount which patient need to pay for healthcare services before
insurance start covering those charges.
38- Co-pay- It is an fixed amount which a patient need to pay on every office visit services. Copay is not
applicable for any surgery visit.
39- Coins- It an share between insurance and patient for health services where insurance will pay the
larger share.
40- Capitation- An amount which, Insurance pays to provider (PCP) in advance for Specific disease is
known as capitation.
41- Recoupment: - In case Insurance pay Extra amount / Excess Amount to provider and that excess
amount is automatically taken by the insurance company is known as recoupment (Auto Debit).
Recoupment can bee only done on same account/encounter.
42- Refund: - In case Insurance pay extra amount/Excess Amount to provider and that Excess amount is
repaid to insurance by provider is known as Refund. (We receive refund request from payer via
correspondence or fax and we toss the claim to Refund team to validate and initiate refund)
43- Offset: - In case Insurance pay Excess amount to provider and that Extra amount is adjusted by the
Insurance company Either with same patient or with other patient in same Entity is known as
Offset.
44- Write-off: - The claims which are refused payment by insurance and the decision cannot be
challenged and amount cannot be collected from patient too & So we write-off balance

45- Adjustment: - Adjustment is the amount that cannot be collected from payer or patient due to
provider issue like non covered as per provider contract, provider missed to take pre-auth# etc.
46- What is clearing house – Clearing house mediate between provider and insurance company who
transmits the claims from provider to insurance and also provides the EOB response from insurance
 to provider. It also checks the edits whether billing format is correct or not if any data is invalid or
incorrect it will get rejected from clearing house.
47- VCC Payment- Virtual credit card payment is of 16-digit credit card number and VCC are sent to
provider via fax or email and they are operated by third party payment department and VCC have a
max of 60 B days validity and If the VCC is not redeemed or expired then payment department
release paper check to billing office address. (Ex Echo)
48- Hospice:- When patient is terminally ill or patient is in his last stage of life. In this denial we will
check What is hospice period. For which dx code patient was enrolled in hospice. to insurance with
similar If claim billed dx code for which patient enrolled in hospice then we need to bill the claim
to Hospice Facility. If dx code billed on claim form is unrelated to dx code for which patient enrolled
in hospice, then we will bill the claim to Medicare Traditional by adding GW modifier.
Appending the GV modifier indicates that the attending physician is not employed or
paid under arrangement by the patient's hospice provider

Can we submit corrected claim to Medicare or Medicaid??

: - No we cannot submit corrected claim to Medicare and Medicaid, Claim always
goes as a Fresh claim.

If we have to do any changes in Medicare claim, then what you will do??
: - If we have to do changes in Medicare claim then we can use Medicare claim Re-
opening option. I am not sure but, I know that there is a Medicare claim re-opening
separate phone-number & need to call and reopen the claim, BUT WE CANNOT
ADD PRICING MODIFIER, we can change ANOTOMICAL OR DIRECTIONAL
MODIFIER, which does not affect code pricing.

Also heard something about.

Written Reopening submissions.
Using Noridian Medicare Portal (NMP) Through appeal function
Also, we can Mail and Fax appeal with complete and clear statement that explains
error or omission with written request form.

How Much Level Of Appeal does Medicare Have?

: - As per CMS Guidelines there is 5 Levels of Appeal.
Level 1 is Redetermination
(Redetermination by a Medicare Administrative Contractor {MAC})
Level 2 is Reconsideration
(Reconsideration by a Qualified Independent Contractor {QIC})
Level 3 is Hearing before an Administrative Law Judge {ALJ}
Level 4 Review by the Medicare Appeals Council (Appeals Council)
Level 5 Judicial Review in United states (U.S.) District Court.
49- Global Denial: We receive global period denial whenever we bill related service during post
operative period of Major surgery or minor surgery code. If the denied cpt code is unrelated to major
or minor procedure code, we can append unbundling global modifier and resubmit corrected claim,
The global period may be of 90, 10, or 0 days, according to type of services.

E&M with modifier 24 will get covered & For global period if related services are billed
then they do not get paid because services rendered was related dx for post-operative
period, for which patient was into global period.
If unrelated services are billed, then they should get paid. Because DX code is unrelated
to DX code for which patient was in Global or Postoperative.
Medicare and Medicaid

50- If claim get denies as primary paid more than secondary allowed amount. We will check
what primary paid and we will check secondary payer fee schedule, as what is the secondary
allowed amount. If primary paid max than, we will adjust the balance.

51- If patient has two insurance and both insurances paid as primary what action you will
take.

Ans : First we will check with the payer whether COB (Coordination of benefit) is updated or
not by patient, mostly in this case's COB would be missed by patient, So we will create
Task to contact patient and Patient needs to update COB to payer.

If AOB Not signed, then Insurance Will Pay to Patient and we will bill to patient &
Also, if nonparticipating provider render services and patient has PPO type Plan which
covers Out of Network Benefits in this case also patient receive payment.

IF Patient have Medicare Traditional plan, Medicare Advantage plan & Medicare
Supplemental plan then which will be the primary, secondary, and tertiary?
: - Medicare Advantage plan is replaced by Medicare traditional plan and So Medicare
advantage plan will act as primary and Medicare Supplement plan will only act as secondary
to traditional Medicare only, So Primary will be Medicare Advantage plan and no More
Payer as Secondary.

52- What is auth denial and why we receive this denial – Authorization requires for major
surgery procedure codes or out of network providers and we have to obtain the prior auth
number for such scenarios before providing the services to patient. Also we do not require
prior auth number for emergency visit and if claim is billed for emergency visit then we need
to ask to rep to reprocess the claim and if rep disagree to reprocess the claim then we can
file reconsideration request. If claim is billed for non-emergence visit and claim denied for
prior auth then we will check box 23 of CMS 1500 & box 63 of UB claim form or in software.
If auth available in software or in claim form then we will check with rep whether that auth
is valid or not for service provided and if auth is valid then we will send this claim back for
reprocess and if it is incorrect we will escalate but before escalating to obtain retro auth we
will check with rep whether they any hospital claim on file or not if hospital claim is on file
need to check with rep whether they have auth on hospital claim or not. If Auth available on
 hospital claim then we will check with rep whether that auth is valid or not for these
services and if auth is valid we will send this claim to reprocess and if auth not valid they we
will escalate to get the retro auth number. (We do not require auth for E/M code and if E/M
code denied for auth that means claim is denied for auth because provider is out of
network.

53- Inclusive Denial: Whenever we receive inclusive denial, first thing we have to call the
payer and check with them against which major CPT code our cpt code denied as inclusive
and them we will check any unbundling modifier added with denied code and if modifier is
already added we will ask to reprocess the claim unbundling modifier like 59, 25 with e/m
code. &
If rep refuse to send the claim back for reprocessing, then we can submit Appeal with
Medical Records &
If no unbundling modifier is added, then we will escalate claim to coding department to
append modifier and after appending modifier need to submit corrected claim. &
We can also identify the bundling relationship with major and minor codes Using NCCI edits.
NCCI edits national correct coding Initiative / it determines the unbundling relations
between major and minor Procedure codes
and also indicates whether we can append unbundling modifier with minor code or not.
there are indicators 0, 1 and 9
0 means we cannot append any modifier to avoid bundling denial & for this the last action
will be appeal. and 1 means we can append modifier. for 9 we cannot append any modifier.
last action would be appealing the claim.
54- Medical necessity – (a ) We receive the Medical necessity denial when
procedure and dx combination is not valid as per the LCD ( Local coverage determination )
or NCD ( Nation coverage determination ). In this case we will check on CMS web portal
whether procedure and dx combination is valid or not as per LCD or NCD policy. If it is valid
we will ask to insurance rep to reprocess the claim and if procedure and dx combination is
not listed in NCD or LCD list then we will escalate this claim to coding department to correct
the dx code.
( b ) - We also get the Medical necessity denial when documentation in Medical records is
not supporting the procedure codes. In this case we can submit the medical records along
with letter of medical necessity which proves the necessity of service.
55- Benefit max denial - For this denial we have to confirm with insurance rep
whether benefit is reached max in terms of visit or dollar value. If benefit max in terms of
visits we will ask the rep how many visits are allowed for that procedure code and how
many visits they have paid. If we receive the denial for benefit max in terms of dollar value
then we will ask with rep what is the maximum dollar value for patient and when patient
exhausted the maximum benefit in terms of dollar value. If we have secondary insurance,
then we will bill this claim to secondary insurance along with primary insurance EOB. If we
 receive the denial of benefit max from Medicaid then we have to adjust the claim or we can
send the Extension letter to Medicaid to consider the claim for payment.
56- Pre-Existing Condition : - Pre-existing condition is health condition which patient had before
taking the insurance policy. In this case we will call the payer and we will check with
condition. If DOS falls within the waiting period and dx code is related to pre-existing
condition then it will not be covered by payer. So, for this we can bill patient. If dx code
billed on claim form is unrelated to dx code for which patient was in Pre-existing condition,
then we will send it for reprocess.
57- Non covered service – When we received non covered denial, we will first check
the update tracker whether we have any update for that denied procedure codes or not
because some procedure codes are non-covered charges, and which are provider
adjustment. If there is no update, we will check with insurance rep whether dx code is not
covered or procedure code is non covered. Also check will check with insurance rep whether
that service is not covered under providers contract or patient benefit plan. If not covered
under patient benefit plan, then we can bill patient if no other insurance available. If
secondary insurance available, we will check with secondary insurance rep whether they
cover the denied service or not. If secondary insurance also does not cover that service in
that case, we can bill patient. If procedure or service denied as non-covered per provider
contract, we will send to coding team to correct the dx or procedure code which causing the
denial.
58- Difference between Participating & Non-Participating Provider: -
Participating Provider/contracted provider Non-Participating Provider/Non- contracted provider
Provider Who agrees with the insurance Provider who disagrees with insurance company
company for Allowed amount as the full & Final allowed amount and expect Full Payment.
Payment.
They have mutual understanding of Contractual They Don’t have mutual understanding.
Adjustment CO-45 (Billed amount-Allowed (Billed Amount-Allowed amount= Balance Bill)
amount= Contractual Adjustment) Balance bill is billed to patient.
High Numbers of patient Low Numbers of patient
Patient Out of pocket is Low (Patient Patient Out of pocket is High (Patient
Responsibility is Low) Responsibility is High)
Auth/Referral is not needed in small services. Auth/Referral is needed in small services too.

52. Taxonomy denial

Taxonomy determines provider speciality and what type of services provider render. (Taxonomy codes
are used by healthcare providers to self-identify their specialty based on which taxonomy code best
matches their specialty) There are two type of taxonomy denial. 1st one is Invalid Taxonomy billed, If we
received this denial then we have to check in our system with which taxonomy code claim was billed
and we will cross verify taxonomy code with NPPES registry portal & if its invalid then we will update
correct taxonomy code in software and send corrected claim.

2nd one is Taxonomy missing in claim form, in this situation, we have to check in our software, weather
claim form was submitted with taxonomy code information or not & If it was submitted with correct info
then need to check in clearing house weather taxonomy code was captured or not, mostly it wouldn't
have captured, so will updated correct taxonomy code in clearing house and submit corrected claim.

Very Important
Medicare Eligibility criteria
Medicaid eligibility criteria
Medicaid Spend Down
Disadvantages of in network and out of network Provider
What if claim is billed to incorrect payer ID / scenario claim not on file
If claim is billed to incorrect payer ID, and claim get paid what you will do:- If claim paid by incorrect
payer then, payer will request for Refund and other scenario we will find claim not on file, need to verify
claim mailing address & Payer ID & TFL & Basic plan information like eff date and term date and
Member ID. with correct payer {REP} and update the information in software and will resubmit fresh
claim.

Difference between Auth# and Referral: - Auth required for High dollar services and out of network
providers and Referral is given by PCP for taking forward the treatment with specialist
REFERAL: (Denial Code PR 165) It is the process of sending patient from one provider to another
provider for special service.
New patient and established patient.
In patient and out of patient
Skilled nursing facility is covered by which Medicare part:- Medicare Part A and Medicare part C
Medicare Parts/Plans
Part A – In-patient
Part B – Out-patient
Part C- Medicare advantage plan (MCO)_ (UHC Medicare hmo/ppo) it replaced traditional Medicare
Part D- DME (lab), Drugs.
Medicare Advantage plan
Medicare supplement Plan.
AOB
ROI
QMB
ABN
Non covered denial
Auth denial#
Hospice
If both insurances paid as primary (COB scenario)

Why you left previous organization. Due to client requirement, they were asking us to relocate to
Chennai and I am financially not stable to take care in both the location so dropped paper in current
Org.

How you get to know of First-Insight company. From my friend of friend from previous organization
Why You want to join First-Insight company: - I have heard, many good things about company as there is
lots of growth opportunity, Good Work culture, Management is very good, Supportive Management,
Will Get to Learn new specialty.
HMO – Health Maintaince organization –

Low Premium, PCP (Primary care Physician ) required when patient want to see any specielist, Out of network
services not covered

POS- Point of service

PPO – Preferred Provider Organization-

Premium High, PCP not required, Out of network provider services are covered

Hospice:- When patient is terminally ill or patient is in his last stage of life. In this denial we will check What is
hospice period. For which dx code patient was enrolled in hospice. If claim billed to insurance with similar dx
code for which patient enrolled in hospice then we need to bill the claim

to Hospice Facility. If dx code billed on claim form is unrelated to dx code for which patient enrolled in hospice,
then we will bill the claim to Medicare Traditional by adding GW modifier.

Appending the GV modifier indicates that the attending physician is not employed or paid under
arrangement by the patient's hospice provider

What is a MUE for CPT codes?

An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast
majority of appropriately reported claims by the

same provider/supplier for the same beneficiary on the same date of service. Not all
HCPCS/CPT codes have an MUE.

A Medically Unlikely Edit (MUE) is a Medicare unit of service claim edit. It's applied to medical
claims for services provided by one provider to one patient on one day