HIPPA to Authorisations (Day 1)

Question 1

What is HIPAA?

Answer 1

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.

Question 2

Mandatory year to have Health Insurance to every citizen of US

Answer 2

2003

Question 3

What is PHI?

Answer 3

PHI stands for Protected Health Information. PHI protects Patient’s Medical Information.

Question 4

What are 3 P’s?

Answer 4

Provider
Patient
Payer

Question 5

Policy

Answer 5

An agreement between Patient and Payer

Question 6

What is Policy ID/Member ID?

Answer 6

It is a unique ID generated when a policy is created.

Question 7

Claim

Answer 7

(Bill) Sent by Provider to the Payer

Question 8

Subscriber

Answer 8

The one who purchases the policy

Question 9

Dependents

Answer 9

Parents, Children & Spouse

Question 10

Enrollment Date

Answer 10

The date when the patient/subscriber purchases the policy

Question 11

Effective Date

Answer 11

The date when the policy starts covering the risks

Question 12

Termination Date

Answer 12

The date when the policy expires

Question 13

Waiting/Cooling period

Answer 13

The gap between enrollment date and effective date

Question 14

Pre-Existing Conditions

Answer 14

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.

Question 15

Date of Service

Answer 15

The date when the patient take treatment or service from the provider

Question 16

Timely Filing Limit (TFL)

Answer 16

Time period set by the Insurance Company/Payer within that time period Provider has to submit the claim to the insurance company

Question 17

Appeal Filing Limit (APL)

Answer 17

Time period set by the Insurance Company, within that time period Provider has to submit an Appeal to the insurance company

Question 18

Date of Denial

Answer 18

The date when the Payer denies the Claim

Question 19

What is OOPS?

Answer 19

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

Question 20

Copay

Answer 20

A small amount of dollar value Patient has to pay at Provider’s office for every visit

Question 21

Coinsurance

Answer 21

A cost shared percentage between the Payer and Patient

Question 22

Deductible

Answer 22

A fixed amount of dollar value Patient has to pay to the Insurance Company before the Policy starts covering the risks (Policy Activation Charges)

Question 23

Prior Authorization

Answer 23

Before performing any high dollar value treatment or critical condition, Provider has to take permission from the Payer

Question 24

Retro Authorization

Answer 24

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.)

Question 25

PCP

Answer 25

Primary Care Physician

Question 26

Referral Authorization

Answer 26

When PCP refers to Specialist

Question 27

Is authorization required for emergency services?

Answer 27

For emergency services, no Authorization is required

Question 28

AFL Calculations starts from?

Answer 28

Date of Denial