Medical Billing

I strongly feel that the Development of PMS Product is more on the domain/business logic other than the technology. So would like to share the information in PMS through my blog. There are lot of articles/books/documents sitting on my desk which I have collected from various sources for the past 10 years. From that, so I will try to educate on that in a simple and easy to understand way with an example when necessary.

Chapter 1: Medical Billing Workflow
1. Medical Billing Use Case

Chapter 2: Medical Billing Process
1. What is Medical Billing Process?
2. Different Format of Medical Form.
3. Patient Insurance

4. Primary, Secondary and Tertiary Insurance Policies
5. Claim Life Cycle – Provider
6. Claim Life Cycle – Payer     
7. Electronic Claim Transmission        
8. Medical Billing Clearinghouse          
9. Medical Billing Process in detail            
10. Healthcare Coding system.           
11. Maintaining Patient Insurance in the software.             
12. What are the Billing Entities?
13 What is Pre Authorization? 
14  What is Assignment of Benefits - CMS 1500 Box 27

         
         
Chapter 3: EDI Transactions

1. What is an EDI?
2. EDI Transactions
3. Understanding EDI Structure (Beginner)
4. Understanding EDI Structure (Detail )
5. EDI Instruction
6. How to Read and Understand EDI File ?              
7. ASC X12 270/271: Eligibility, Coverage, or Benefit Inquiry 
8. Rejection Followup Using Claim Acknowledgement EDI 277CA
9. Difference between 277CA and 277      
10. Difference Between 837 Institutional and 837 Professional        
11. EDI 5010 Documentation 837 Health care claim: Professional      
12. EDI 270 - 5010 Health Care Eligibility/Benefit Inquiry          
13. Claim Forward to other Insurance
14. Difference between claims and encounters EDI 837 transactions
15. Understanding EDI 835 Health Care Claim Payment/Advice Transaction
16. X12 EDI Examples with Payer Claim Number
17. Map claim information between EDI 837 and EDI 837
18. Understanding EDI 999 functional Acknowledgement – Example 1
19. EDI 837 Professional Loops

 

Chapter 4: Payment
1. EOB – Explanation of Benefits
2. Understanding EOB - Explanation of Benefits
3. Understanding EDI 835 Electronic Remittance Advice
4. What is Copay, Co-Insurance, and Deductible in Insurance Payment Posting?
5. Types of Reimbursement
6. How to process Copay, Co-Insurance, and Deductible Amount in Insurance Payment Posting?

Chapter 5: Claim Submission after Primary Insurance
1. How to submit the claims after primary insurance?

Chapter 7: Claim Processing by the insurance company
1. Claims adjudication and Payment process.?

 

New to Health care Domain? Here are some documents which can help you to understand the basics. I am trying to refer to the official link(where I downloaded the document) and as well as a link to my server(sometimes, official links are broken).

1. Introduction_to_Health_Care_in_USA (or you can click here to download)
2. Medicare Incentive Program Beginners guide MU Stage 1 ( or you can click here to download)

All about Prescription

•  An Introduction to ePrescription
•  How ePrescribing works
•  Paper Prescription workflow
•  Electronic Prescription workflow
•  Refill Paper Prescription workflow
•  Refill Electronic Prescription workflow

Flow charts

• Medical Billing Overview
• Rooming Overview
• Medical Billing Flow chart
• EMR Test Visit Flow chart
• EMR Patient Examination Flow chart
• EMR Office visit Flow chart
• Medical Claim Life Cycle
• Claim Adjudication and Payment Flow chart
• EMR Office Visit
• Billing Flow chart

Medical Billing blogs

• Blog on Medical Billing – Revenue Cycle Management
• Medical Billing and Coding
• Medical billing CPT modifiers
• CMS 1500 claim and UB 04 form
• Medicare Fee Schedule, Payment and Reimbursement
• Insurance claim denial and appeal