HIPPA to Authorisations (Day 1) Flashcards
What is HIPAA?
HIPAA stands for Health Insurance Portability & Accountability Act 1996. HIPAA regulates overall medical billing business in the USA. Whoever indulges in this business like Doctors, Insurance Companies, Nurses, Outsourcing companies should be HIPAA certified. HIPAA has one clause called PHI (Protected Health Information) which protects the patient’s medical information.
Mandatory year to have Health Insurance to every citizen of US
2003
What is PHI?
PHI stands for Protected Health Information. PHI protects Patient’s Medical Information.
What are 3 P’s?
Provider
Patient
Payer
Policy
An agreement between Patient and Payer
What is Policy ID/Member ID?
It is a unique ID generated when a policy is created.
Claim
(Bill) Sent by Provider to the Payer
Subscriber
The one who purchases the policy
Dependents
Parents, Children & Spouse
Enrollment Date
The date when the patient/subscriber purchases the policy
Effective Date
The date when the policy starts covering the risks
Termination Date
The date when the policy expires
Waiting/Cooling period
The gap between enrollment date and effective date
Pre-Existing Conditions
Before purchasing the policy if the patient gets diagnosed with any existing disease it is called a pre-existing condition. For example: asthama, cancer, disabilities, etc.
Date of Service
The date when the patient take treatment or service from the provider
Timely Filing Limit (TFL)
Time period set by the Insurance Company/Payer within that time period Provider has to submit the claim to the insurance company
Appeal Filing Limit (APL)
Time period set by the Insurance Company, within that time period Provider has to submit an Appeal to the insurance company
Date of Denial
The date when the Payer denies the Claim
What is OOPS?
Out Of Pocket Expenses which was introduced in the year 2015. In OOPS, 3 things were introduced which are:
1) Copay
2) Coinsurance
3) Deductable
Copay
A small amount of dollar value Patient has to pay at Provider’s office for every visit
Coinsurance
A cost shared percentage between the Payer and Patient
Deductible
A fixed amount of dollar value Patient has to pay to the Insurance Company before the Policy starts covering the risks (Policy Activation Charges)
Prior Authorization
Before performing any high dollar value treatment or critical condition, Provider has to take permission from the Payer
Retro Authorization
If in case Provider missed out to take Prior Authorisation then he has an option to obtain authorisation after providing the service.
(TFL for Retro Authorization depends on Insurance Guidelines.)
PCP
Primary Care Physician
Referral Authorization
When PCP refers to Specialist
Is authorization required for emergency services?
For emergency services, no Authorization is required
AFL Calculations starts from?
Date of Denial
