Work/ Job Profile: I was posting the payment through EOB, and ERA which was received from

insurance
company,

and EOB for manual Posting and ERA auto posting.

Insurance Company name: Medicare, Medicaid, Aetna, BCBS UHC,

Software: Entergy, eCW, (MM Medical Manager) ,PHI

Target for manual posting: 400 claims

and Auto Posting: 1200 claim

EOB: Explanation of Benefits): - This is a document that is sent by insurance company to the provider which
contains all the payment or Denial Details. It is use for manual posting.

EFT - electronic fund transfer is a mode of payment

Surgery - 10040 – 69990. Radiology - 70010 – 79999

L6 interest payment

• Cross over . Medicare payment ke baad sec insurance pay karati hai use cross over kahate

ERA: Electronic Remittance Advice): It is digital form of the EOB and it is use for auto posting

WO or Offset : When an insurance make access or incorrect payment on previous claim they
adjust that amount in the next EOB. That is called Offset.

in EOB it shows as WO with claim no. or tracking number

Re-fund: When an insurance company make access or incorrect payment, they take back that
amount is called refund. Non-Par.

Recoupment: When an insurance company process incorrect EOB, then they take back the entire
payment, adjustment and PR amount is called the recoupment

FB)Forwarding balance: Like forwarding balance is future offset there are negative balance and positive
balance adjust.

Copay (PR3): It is a small dollar amount which is paid by the patient to provider on every visit. It is a just like
doctor fee.

Co-insurance (PR2): It is specified (%) percentage of allowed amount which patient or secondary Ins. has to
pay to the provider.

Deductible (PR1): It is a fixed amount which is paid by patient to the provider on annual basis only then after
insurance company start giving benefit to the patient.

Write off Amount: The difference between billed and allowed amount in case of participating provider is
called as write – off amount.

Balance Bill: The difference b/w billed and allowed amount. In case of non-participating provider is called as
balance bill.

Allowed Amount: The fix amount which is set by insurance company for the services performed by the
provider is called allowed amount.
out of pocket expenses.

Deductible, Co-insurance, Co-pay & balance bill are out of pocket expenses.

Expenses: (Patient pay by his pocket) A medical bill or a part of a medical bill paid by patient out of
his own pocket, because of non-payment of his insurance Company is called an out-of-pocket
expense.

TFL: Timing Filing Limit): This is a time duration which is given by insurance company in which we
have to submit the claim to the insurance company. This is calculated from date of service.

PCP: Primary Care Physician): PCP is equivalent to the family doctor which refers the patient to
specialist.

Participating Provider (In – Network Provider): those providers who are having the contract with
the insurance company. is called Participating Provider.

Non – Participating Provider (Out of network provider) : Those provider who are not having the
contract with the insurance company is called NON Par..

This is a fix amount which insurance company has to pay to the provider on
Capitation: monthly basis

Adjustment code:

CO 45: Contractual adjustment. (White off)

CO 253 (Sequestration adjustment): It is a 2% of Medicare payment reduction and it kinds of adjustment .

Medicare Insurance: It is Nation government insurance and to get the Medicare insurance there are
eligibility criteria.
1st Any us citizen who is 65 years old or above.

2nd A person suffering from end stage renal disease (ESRD)

3rd A person with permanent disability.

Medicare new Id Format: 11-digit alfa numeric number

What is Medicaid: It is a state government program for low-income group. It is last payer.

State wise id

Difference between HMO & PPO:

HMO (health maintenance organization PPO(Preferred Provider Organization

In HMO plan patient can only go to the
Participating Provider (Referral no. is required).
In HMO plan patient first go to the PCP and if
specialist treatment required the PCP refer the
patient to the specialist with the referral no.
In PPO plan patient can go to the
participating provider as well as to the nON-
participating providers.
In PPO Plan patient can directly go to the
specialist without a referral from PCP.
Day Activity Payment: First my team lead assign the batches and we just start posting those batches in system and for
manual posting we open the EOB and first we just create the batch and open first account in system and we just need to
match patient name and date of service, CPT if all details match then we just post those payment in system. End of the
day we prepare the recon sheet and mention all the posted batch details in that sheet.

reconcilation > For reconciliation if any batch did not reconcile then I was pulling the system generated report then after I
match one by one payment through EOB, Once I found the difference in any payment then we post that amount and
reconcile the batch.

Modifiers: Modifiers are two digit alpha numeric code that alert the procedure code ( CPT) W/O
changing it.

21 - When provider expends extra time with patient

24 - Post operative period
25 - When provider perform procedure with E&M than use
25 modifier with E&M code.
26 - When patient gets services outside. Then facility not available in hospital. (Professionals
Services)
51 - Multiple Procedures other than E&M
52 - Reduce Services
59 - Separate Services from other provider on same day (Distinct Procedure)
76 - Repeat procedure by same Physician ,
77 - Repeat procedure by other Physician
RT - Right side of Orgen.
LT - Left side of Orgen

Important Denial codes: we just post the zero payment and forward those case to AR.

CO: 16 described as "Claim/service lacks information or has submission/billing error(s) which is required for adjudication"
CO:18 described as "Duplicate Claim
CO:22 described as "This service may be covered by another insurance as per COB"
CO:27 describe as Expenses incurred after coverage terminated
CO:29 Described as "TFL has expired".
CO:96 It is for NON covered charges

0 CO18 DUPICATE OK CLINK

Billed amount 500

Allo 300

PAID 250

CO45 -0

PR – 300-250=50 PAINT