Non-surgical cleansing of a wound without sharp debridement might be separately reimbursable using the appropriate service codes (51-01, 51-02 and 51-03); for the following services appropriate CPT codes must be used: wound debridement, dressing for burns, and dressing change under anesthesia.

An established patient has received professional services from the same physician or another physician in the same specialty and subspecialty in the same group practices, within the past three years.

A new patient is the one who has not received any professional services from the same physician or another physician in the same specialty and subspecialty in the same group practices, within the past three years.

In ER all patients considered as new patient.

Diagnosis related grouping

It’s applicable for both inpatient and outpatient visits, however currently in Abu Dhabi it is being used only for IP admissions.

CPT code is 36415. Payment for Venipuncture shall be allowed only if an outside laboratory was utilized and the lab samples are drawn in a provider’s office.

Modifiers are two-character codes that add clarification and additional details to the procedure code’s original description, as listed in the main portion of the Current Procedural Terminology (CPT) book.

None of the modifiers are currently mandated in Abu Dhabi…

Inappropriate billing of additional CPT codes that by definition these additional codes are already included in the reimbursement of the primary procedure.

Current Procedural Terminology- is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.

The International Classification of Diseases - is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD is used by physicians, nurses, other providers, researchers, health information managers and coders, health information technology workers, policy-makers, insurers and patient organizations to classify diseases and other health problems.

Outpatient

Evaluation and Management - E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.

Diagnosis Related Group - a statistical system of classifying any inpatient stay into groups for the purposes of payment.

HCPCS stands for Healthcare Common Procedure Coding System. A standardized coding system used to process claims for insurance payments.

Resubmitting the claims by review and analyze the reasons of rejected payment for the claimed services with the help of denial codes provided by payer (Insurer) as per HAAD standard.

Claim or Services rejected from the payer or insurer by stating the submitted services are not eligible for the payment due to lack of information provided by the healthcare provider.

Insurer an insurance company licensed by authority to provide health insurance services. Payer refers to insurance companies who reimburse the healthcare provider for the medical services rendered to their insured members.

Rejections are classified into two categories Administrative and Medical Rejections.

Remittance Advise is the summary of payment and rejections received from insurance companies for invoices submitted from the healthcare provider.

Extensible Markup Language (XML) is a markup language that defines a set of rules for encoding documents in a format which is both human-readable and machine-readable.

Receiving RA through HAAD post office (Green Rain Messenger) in xml format.

Resubmission files are being uploaded through HAAD post office (Green Rain Messenger) in xml format.

• Correction
• Internal complaint
• Legacy

Third Party Administrator – is an organization which processes claims as a separate entity it also administrates group insurance policies. They work with the employer as well as the insurer to communicate information between the two, as well as processing claims and determining eligibility.

A person who receives benefits of any insurance plan or policy.

A person or organization that provides medical services.

Our primary concern is for your health and safety. We request patient’s identification to ensure that we access and update the correct medical record. It’s also to protect the patient from fraud.

In order to file an insurance claim on patient’s behalf, it is necessary to make certain that we have the most current and accurate information about your insurance coverage and specific plan benefits.

Accurate registration benefits everyone, including patients/guarantors, providers and insurance companies during this process. Information in hospital records is confirmed or updated to ensure accurate claim submissions with insurance.

Deductible

A deductible is usually a fix amount that patient have to pay out of own pocket before the insurance will cover the remaining eligible expenses. Depending on the insurance plan, the deductible can range from 0 AED all the way up to thousands.

Coinsurance

Coinsurance is usually a percentage, and represents the percentage cost that patient will need to pay and the insurance plan will pay towards eligible medical expenses. Some common coinsurance examples include: 100%, 80/20, 90/10 and 50/50 – so if patient have 80/20 coinsurance on insurance plan, it means that the insurance company will cover 80% of medical cost and patient is responsible for paying the other 20%. 

Copay (copayment)

Copays are similar to deductibles, in that it is usually a fixed amount of money patient have to pay each time when they are using their insurance.

With most insurance plans, you will typically see some combination of deductible, coinsurance and copayments – or in some insurance plans may not have any of them. It will very much depend on specific insurance plan so be sure to check the policy details and let patient know what their out-of- pocket payments will be.

Services for which an insurance policy will not provide payment. These services are to be paid by the patient at the time of service.

Patient will be responsible for charges your insurance company does not authorize or cover. It is recommended that you contact the ordering provider to discuss whether to receive the service and for other possible funding services.

A parent or legal guardian must accompany patients who are minors on the patient’s first visit. The accompanying adult is responsible for payment of the account.

Some health insurance policies only pay for health care up to a certain amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual limit. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy-holder must pay all remaining costs.