US HEALTHCARE

OVERVIEW
Process: Contract Loading
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HEALTH INSURANCE
Health insurance is a mechanism to reduce individuals risk of incurring high medical
expenses in the future that he may be unable to pay. In order to cover these possible
future medical expenses a person pays periodic payments premiums!" to an insurance
company. #hese $remium payments allo% that person to be enrolled %ith the company.
#hat person is then referred to as an &enrollee' or &insured'. All other individuals %ho
en(oy the benefit of the plan are referred to as &covered'. Health care insurance or health
insurance is a contract bet%een a policyholder and an insurance carrier or government
program to reimburse the policyholder for all or a portion of the cost of medically
necessary treatment or preventive care rendered by health care professionals.
AMERICAN HEALTHCARE INDUSTRY
Health conscious
$ractice preventive medicine
)onstant intervention of government
)ontinuous increase in investment
Access to professional and speciali*ed medical care
+a(or part of American population in age group of ,- . /- years
INSURANCE PLAN
Insurance coverage is referred to as an &insurance plan' and covers services that %ere
previously agreed to. Individual is given a health insurance card on purchase of the
&insurance plan'" %hich contains details of the patients insurance policy.
A policyholder is not eligible for health insurance unless and until he0she pays the pre1
determined premium specified by the insurance.
COMPONENTS OF INSURANCE PLAN
$remium to be paid
Services covered
Services not covered
$atients responsibility on a bill0claim
$rovider net%ork
HEALTHCARE REIMBURSEMENT
&Healthcare 2eimbursement' is the charging of and receiving payment for provider
services rendered to a patient. 3hile a patient is responsible for paying some of the costs
associated %ith treatment" the patients payor pays the bulk of the costs directly to the
provider. #hus" the entity paying for a patients care is called a third party payor.
HOW IS PROVIDER PAID BY HEALTH INSURANCE?
4nce patient receives treatment or evaluation" the provider compiles diagnostic and
insurance information. )linical and charge information is coded. A claim is generated and
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submitted to the insurance carrier. #he insurance carrier revie%s bill0claim and
reimburses provider according to contract or reimbursement agreements. $rovider
receives payment as per contractual or reimbursement arrangement.
REIMBURSEMENT PROCESS
3hen a provider first sees a patient for treatment" the patients health insurance
and clinical information is compiled. All clinical and charge information are
coded %hile the patient receives the treatment.
After treating a patient" the provider sends a bill directly to the patients insurance
carrier.
#his provider bill is called a claim.
#he patients insurance carrier pays for the patients covered services by
sending a payment directly to the provider.
4nly if some providers services are not paid by the payor" %ill the provider send
a bill for the remaining services to the patient. If the patient does not have health
insurance" he is responsible for the entire provider bill.
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HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT -HIPAA
#his la% helps to protect ones rights to health coverage. It also provides rights and
protections for employers %hen getting and rene%ing health coverage for their
employees. HI$AA is NOT an insurance policy. #he )enters for +edicare 7 +edicaid
Services )+S! is responsible for implementing.
HI$AA provides rights and protections for both group health plans and individual
coverage. #hese rights and protections address8
$ortability 1 3hether you can get ne% health coverage if you %ant to change
coverage
Availability 1 3hether health coverage must be offered to you and your
dependents
2ene%ability 1 3hether you are able to rene% health coverage
#he $rivacy 2ule for the first time creates national standards to protect individuals9
medical records and other personal health information8
It gives patients more control over their health information.
It sets boundaries on the use and release of health records.
It establishes appropriate safeguards that health care providers and others must
achieve to protect the privacy of health information.
It holds violators accountable" %ith civil and criminal penalties that can be
imposed if they violate patients9 privacy rights.
And it strikes a balance %hen public responsibility re:uires disclosure of some
forms of data 1 for example" to protect public health.
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PARTICIPANTS IN US HEALTHCARE SYSTEM

$atients
$roviders
$ayors
Suppliers
2esearchers
;usiness Associates
PATIENTS
$atient is also called beneicia!"8 person %ho has a medical condition illness or
diseases! and gets in contact %ith the medical provider for healthcare services.
PROVIDERS
$roviders are individuals" corporations" institutions" or facilities %ho are licensed by the
government to provide medical care" services" goods and supplies to patients.
E#am$le% & $!&'i(e!%8 $hysicians" <urses" Hospitals" and <ursing homes" =mergency
room technicians" Ambulatory surgery centers.
PHYSICIANS
PCP) $rimary )are $hysician in general term is a family doctor or the doctor one %ho is
visited by the patient first for any kind of health problem. $rimary care physicians are
also called *a+e ,ee$e!%" as they are the ones %ho are contacted first by the patient. $)$
is also called !ee!!in- (&c+&!
>amily $ractice0?eneral $ractice All age groups!
Internal +edicine 1,11@!
$ediatrics -11,!
Adolescent +edicine
S$eciali%+) Specialists are physician %ho practice on a particular specialty. Some of the
practitioners are Aentist" 4ral Surgeon" and )hiropractor. A specialist can also be a $)$
for the patient. In cases %here the patient directly comes to the doctor for his health
problems and the doctor diagnosis some problem" %hich is also his specialty" then he
becomes the $)$ and Specialist for the patient. Specialist is also called !en(e!in- (&c+&!
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4rdering $hysician8 4rdering $hysician is a physician %ho orders for non1physician
services for the patient such as diagnostic laboratory tests" clinical laboratory tests"
pharmaceutical services" and durable medical e:uipment.
All claims for insurance covered services and items that are the result of a physician9s
order or referral must include the ordering0referring physician9s name and Uni./e
P0"%ician I(en+iica+i&n N/mbe! 1UPIN23
Ca+e-&!" & P!&'i(e!%
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P!&'i(e!
In(i'i(/al Facili+"
- Hospital
1 Ambulatory Surgery )enter AS)!
1 Skilled <ursing >acility S<>!
1 Home Health
1 Hospice
Allie( Heal+0 P!ac+i&ne! 1AHP2
E#) A)" 4A" $HA" $SDA" L)S3"
$# etc.
P0"%ician
Ti+le4De-!ee1+A" A4" A$+"
A+A" AAS
P!ima!" Ca!e P0"%ician 1PCP2
1 >amily $ractice0?eneral $ractice
1 Internal +edicine
1 $ediatrics
1 Adolescent +edicine
S$eciali%+
E#- )ardiology" <eurology"
Aermatology etc.
P0"%ician E#+en(e!% 1PE2
E#) )<+" )2<$" )2<A"
$A etc.
FACILITY PROVIDERS
>ollo%ing are the most common facility providers8
Hospitals
Ambulatory Surgery )enter AS)!
Skilled <ursing >acility S<>!
Home Health
Hospice
HOSPITALS
A Hospital today is a center for professional health care provided by physicians and
nurses. It is a facility that provides the most intensive and comprehensive medical
services available. Hospitals are generally classified as ?eneral Hospital" Speciali*ed
Hospital" and +edical )enters.
CARE E5TENDED AT HOSPITALS
Inpatient8 A person %ho is admitted to the hospital so that he may receive care overnight.
4utpatient8 A person %ho receives hospital services but does not need to receive care
overnightE outpatients are not admitted but can be under observation for some hours.
=mergency8 A person %ho re:uires immediate service because the illness is severe or life
threatening.
AMBULATORY SUR*ERY CENTER 1ASC2
Ambulatory surgery is surgery that does not re:uire an overnight hospital stay. It is also
called FAay Surgery" FSame Aay Surgery SAS!" or FShort $rocedure Gnit S$G!. AS)
may either be affiliated %ith a hospital or have no affiliation %ith a hospital. Ambulatory
Surgery )enters act as autonomous units and are treated as separate entities.
Ambulatory programs offer patients the convenience of being treated and released the
same day %ithout being admitted to the hospital. #his means that eligible patients come
to the hospital either in the morning or afternoon of the day of surgery" undergo the
operation" or are discharged %ithin the same day to recover in the comfort of their home.
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It is a freestanding facility" other than a physicians office" that operates exclusively to
provide surgical services to patients %ho do not re:uire hospitali*ation.
S,ILLED NURSIN* FACILITY 1SNF2
S<> is a facility that primarily provides inpatient" skilled nursing care and related
services to patients at a lesser intensity than an acute facility hospital!. S<>s are used for
patients %ho need medical" nursing care" or rehabilitation services.
$atients are usually treated on a long1term basis and care is less expensive than in a
hospital. #he most common S<> facility is a nursing home. #hese facilities are usually
run by nurses and %ould (ust have a visiting doctor on call.
HOME HEALTH
Home Health agencies are organi*ations" %hich are engaged in providing services
medical and non1medical! to patients and their families in their home or place of
residence according to a %ritten plan of treatment signed by the patients physician.
#hese services are delivered at home! to recovering" disabled" chronically" or terminally
ill persons in need of medical" nursing" social" or therapeutic treatment and0or assistance
%ith the essential activities of daily living.
HOSPICE
Hospice programs make it possible for terminally ill persons to spend the final stages of
their lives at home or in home1like settings. An emphasis on palliative and supportive
care %ill enable them and their families to cope %ith this difficult transition.
Hospice can be hospital1based or freestanding. 4nly terminally ill patients are eligible for
hospice care.
RESEARCHER
Healthcare 2esearchers are persons or organi*ations that use scientific methods to
discover ne% causes of morbidity" methods of treatment" or %ays to avert illness. #his
research leads to technological advances in the healthcare.
E#am$le%) <ational Institute of Health <IH!" #he Gniversity of +ichigan G of +!" and
$harmacia )orporation.
SUPPLIERS
Suppliers are organi*ations that sell healthcare products to providers to be used in the
delivery of healthcare.
E#am$le%) +erck" Hohnson and Hohnson
BUSINESS ASSOCIATES
HI$AA defines a &;usiness Associate' as an individual or corporate person %ho performs
on behalf of the covered entity any function or activity involving the use0disclosure of
$rotected Health Information $HI! and is not a member of the covered entitys
%orkforce.
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)overed entity discloses $HI to a business associate and allo%s it to create0receive $HI
on its behalf only if the covered entity executes a satisfactory contract or other %ritten
agreement =x8 +emorandum of Gnderstanding!.
PAYORS
A $ayor is an organi*ation that has contracted %ith a patient to pay for a patients
healthcare services. $ayor may be either government agencies or private companies.
$rivate companies %ho pay for patients healthcare services are called insurance
companies. =ach payor has its o%n set of covered benefits" payment mechanism" and
regulations.
E#am$le%)
Aetna" )igna" ;);S" Humana etcI
TYPES OF PAYORS

+edicare
+edicaid
;lue )ross and ;lue Shield
)ommercial Insurance
+anaged care 4rgani*ations
3orkers )ompensation
<o1>ault
#2I)A2=
MEDICARE
+edicare is a federal government health insurance program %hich pays for certain
healthcare services and originated from a federal la%" title JKIII of the Social Security
Act.
+edicare is health insurance program for people age CB or older. )ertain people younger
than age CB can :ualify for +edicare" too" including those %ho have disabilities and those
%ho have permanent kidney failure. #he program helps %ith the cost of health care" but it
does not cover all medical expenses or the cost of most long1term care.
+edicare is managed by )enters for +edicare and +edicaid Services )+S!" %hich
covers nearly ,- million Americans and provides coverage for8
$eople age CB or older"
Some people under age CB %ith disabilities"
$eople %ith =nd1Stage 2enal Aisease =S2A!" %hich is permanent kidney failure
re:uiring dialysis or a kidney transplant.
+edicare consists of t%o parts8 $art A and $art ;
Pa!+ A
Hospital insurance plan financed mostly through taxes on employers and employees.
$ersons %ho :ualify for +edicare receive $art A automatically. A beneficiary or
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beneficiarys spouse must have paid Social Security #axes or premiums for at least 1-
years0,- :uarters.
Pa!+ B
Supplementary medical insurance that pays for physician services and other services not
covered under $art A. persons %ho :ualify for +edicare do not automatically receive $art
;. #hese individuals must purchase $art ;.
MEDICARE6CHOICE &! MEDICARE PART C &! MEDICARE ADVANTA*E
+edicare M )hoice is also called +edicare +anaged )are $rogram" %hich is offered by
private insurance companies under the regulations and guidelines of +edicare. $art )
covers all services of +edicare $art A and ; plus some additional services. #here are a
number of +edicare +anaged )are $lans that one can choose from at a premium. In
order to be eligible to buy $art ) one must be eligible for $art A and one must necessarily
buy $art ;. $art ) covers services such as hearing aids" eyeglasses" dental services etc.

MEDICAID
+edicaid is a program that pays for medical assistance for certain individuals and
families %ith lo% incomes and resources. It originates from title JIJ of Social Security
Act. It is (ointly funded by >ederal and State governments to assist states in furnishing
medical assistance to eligible needy persons. +edicaid is the largest source of funding for
medical and health1related services for Americas poorest people and covers 6C million
individuals.

BLUE CROSS AND BLUE SHIELD 1BCBS2
;);S is a not1for1profit entity that offers health insurance through more than /- different
organi*ations located in every state. 3ithin general guidelines" each individual
organi*ation operates as a separate company %ith its o%n benefits and payment policies.
;);S %as one of the first private health insurance organi*ationsE therefore" it has a large
enrollee population. It offers only health insurance" both for individual and group plans.
;);S also offers commercial and managed care plans although ;);S is not a
commercial or managed care company!.

COMMERCIAL INSURANCE
)ommercial insurance can be a type of company or type of plan offered by company.
)ommercial insurance company )arrier! . #hese are private" for1profit those companies
%hose goal is to make money! companies. 4ffer more than (ust health insuranceE they
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may also offer auto" life" and home insurance. )ommercial insurance is financed by
enrollee premiums.
)ommercial insurance plan Indemnity! . #ypically" the insurance company %ill pay @-N
of claim %hile the patient pays 5-NE another common arrangement is %here company
pays /-N of claim %hile the patient pays 6-N.

MANA*ED CARE
+anaged )are can be a type of company or type of plan offered by company.
+anaged )are )ompanies8 Are both for profit and non1profit companies" %hich offer
only" managed care plans
+anaged )are $lan8 #here are three common types of managed care plans8 Health
+aintenance 4rgani*ation" $oint of Service 4rgani*ation" and $referred $rovider
organi*ation. =ach plan has a different balance of a patients cost for the plan. In general"
the more choice a patient has of %hich provider he can see" the more expensive the plan.
+anaged care is different from )ommercial Insurance because it attempts to &manage a
persons care' by restricting the providers an enrollee can visit. +anaged care usually has
cheaper premiums than )ommercial insurance.
PREFERRED PROVIDER OR*ANI7ATION 1PPO2
$$4 is made up of group of providers %ho have simply agreed to discount their services
for a specific insurance planE this provider group is generally much larger than the
net%ork in an H+4 and $4S.
3ith $$4s" a $)$ or even the group of providers does not manage a patients careE a
patient can see any physician he %ants to among the providers offering discounts. 4ut of
all managed care plans" $$4s give patient the most choice of providers and so they are
the most expensive plans. Also" patients are not re:uired to visit a $)$ before visiting a
specialty care physician.
HEALTH MAINTENANCE OR*ANI7ATION 1HMO2
H+4 consists of a net%ork of physicians" hospitals" and other healthcare providers that
have contracted %ith an insurance company to manage an enrollees care. Services
rendered by providers outside of net%ork are not eligible for coverage.
3ith an H+4 plan" a patient must first refer a primary care physician $)$!E the $)$
then manages the patients care and may refer that patient to other provider if necessary.
H+4s are generally the least expensive managed care plans for enrollees because this
type of plan has the most restrictions on provider choice.
POINT OF SERVICE 1POS2
In $4S" patients have the option of using in1net%ork providers or out1of1net%ork
providers. A $4S plan %ill reimburse services received from in1net%ork providers at a
higher rate than out1of1net%ork providers.
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If the patient remains in1net%ork" the patient must still use a $)$ to coordinate careE
patient %ho seeks out1of1net%ork care does not need to go through a $)$. )laim received
from the out1of1net%ork providers may be re(ected or paid at a lo%er rate. Also the
patient responsibility on a bill %ould be higher if he goes out of net%ork.

WOR,ERS COMPENSATION
3orkers )ompensation provides disability income to employees %ho are unable to %ork
due to an in(ury that occurred on the (ob. It is an insurance system for employees %ho
have become ill or in(ured %hile at %ork. #his plan covers only %ork related problems.
=mployees are eligible to receive a percentage of their %ages and medical care depending
on the time needed before they can %ork again and the extent of medical treatment
needed.
If an employee gets high fever %hile at %ork and this is not due to his %orking condition
it %ill not be covered under 3orkers )ompensation" as the fever %as not due to the
nature of %ork.
3orkers )ompensation is funded by employer taxesE employees cannot be charged any
premiums and there is no patient responsibility on these bills. 3orkers )ompensation is
re:uired by the government but varies by stateE each state has its o%n rules and
regulations and fee schedule0G)2 rates.
NO FAULT
;asically" no1fault insurance is %hat its name suggests8 theres no fault placed in the
event of an accident. #he drivers involved %ould submit a claim to their o%n insurance
companies and receive compensation from them rather than target one another" trying to
figure out %hos to blame.
<o1fault insurance is not offered in every state. State governments govern it and so each
state has its o%n coverage stipulations and regulations. States that offer <o1fault
insurance are called F<o1>ault States.
CHAMPUS 1TRICARE2
)HA+$GS" the )ivilian Health and +edical $rogram of the Gniformed Services" is a
federally funded health care program that provides hospital and medical services to
dependants of deceased or active duty service personnel" retired service personnel and
their dependants" and $ublic Health Service Individuals.
CHAMPVA
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)HA+$KA" the )ivilian Health and +edical $rogram of the Keterans Administration" is
a program by the Keterans Administration that shares the cost of medical bills of veterans
%ith total or permanent service1connected disabilities %ith their spouses and children or
surviving spouses or children of veterans %ho died as a result of service connected
disabilities.
PRIMARY INSURANCE
+any people in GS have more than one insurance coverage. #hey may have up to three
insurance coverage9s. #his is possible if one person is the subscriber to t%o policies" a
person subscribes to one policy and is covered under his spouses coverage or the person
may be a dependent of t%o %orking parents. In these cases" one insurance company takes
first responsibility for the patients medical bills. It %ould pay ma(or portion of the bill.
#his %ould be patients primary coverage.
SECONDARY INSURANCE
3hen a patient has more than one insurance company" the insurance that is responsible
for balance on a bill after the primary insurance has paid" is the secondary insurance.
#hey %ill pay their portion of the bill based on %hat the primary has already paid. #o
determine their portion of the bill they %ill re:uire a copy of the primary insurances
=4;. >or this reason" a secondary claim is al%ays sent %ith a copy of the primary =4;.
PAYMENT MEHTODS AND CONTRACTUAL TERMS)
$ayors pay providers according to a contract that they both have signedE in absence of a
contract" reimbursement is based on 1--N of billed charges. 3ith rising healthcare costs"
payors are constantly seeking payment methods" to encourage providers to reduce
healthcare expenses.
In general" payors use the follo%ing four bases to calculate provider payments8
)harges
)osts
>lat rate
)apitation

CHAR*ES) $ayments are based on %hat a provider charges. #his is the historic
payment method and not commonly used today as theres no incentive for the physician
to cut costs the more a physician charges" the more he is paid!.
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COSTS) $ayments are based on %hat cost a provider has incurred in treating a
patient. Still used today" but slo%ly being phased out because here is not enough
incentive for a provider to cut costs. $ayment methods used are FG)2 and F$I$.
U%/al8 C/%+&ma!"8 &! Rea%&nable 1UCR2) $roviders paid according to the
providers usual fee" the customary fee of other providers in the area" and the
reasonable fee for the service.
Pe!i&(ic In+e!im Pa"men+ 1PIP2) $rovider paid a fixed amount on a regular basis
according to costs. #his is usually used %ith facility providers. >inal reconciliation of
underpayment0overpayment is made at the end of the contract.

FLAT RATE)
>ixed provider payments per episode of care regardless of intensity of services or length
of servicesE ho%ever provider is not paid unless service is rendered.
FLAT RATE PAYMENT METHODS
Per Diagnosis 1 >ixed payment based on patient diagnosis.
Per Diem 1 >ixed payment per day.
Per Admission 1 >ixed payment based on patient admission regardless of diagnosis or
number of days.
Fee-For-Service 1 $roviders charge individually for each service provided to a
patient.
Fee Schedule 1 >ixed payments for specifically outlined units of service or all listed
fee1for1service in contract.
CAPITATION)
>ixed payments paid to a provider periodically for each patient assigned to the provider.
#he provider is paid regardless of %hether the patient is ever seen. #he most common
arrangement is $er +ember $er +onth $+$+!.
Specified amount paid periodically to health provider for a group of specified health
services" regardless of :uantity rendered.
RESPONSIBILITIES OF PATIENT)
$ortion of health services0health costs that must be paid for by the plan member"
including premiums" deductibles" co1payments" and co1insurance.
4ut of pocket expenses also refer to the payment of services not covered by or approved
for reimbursement by the health plan.
CO-PAYMENT
A small" fixed amount a patient directly pays a provider for specific services. It is
a upfront payment a patient has to pay every time a patient visits a physician or
hospital.
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DEDUCTIBLE
A fixed amount per contractual period that a patient pays before health insurance
%ill begin to payE this is only paid if provider services are obtained.
CO-INSURANCE
A fixed percentage a patient pays for services received after a deductible and co1
payment have been paidE the insurance company pays the remaining percentage.
PREMIUMS
#he regular payment a person makes to an insurance company to obtain health
coverage. $remium has to be paid even if the policyholder does not visit a
provider in the coverage period.
NETWOR,
A list of physicians" hospitals and other providers %ho provide healthcare services to the
beneficiaries of a specific +)4! +anaged )are 4rgani*ation.
PARTICIPATIN* PROVIDER
A provider that has contracted %ith an insurance carrier or +anaged )are plan to provide
health services to plan members. #hey are deemed to be &In1<et%ork $roviders'.
NON-PARTICIPATIN* PROVIDER
A provider that does not sign a contract to participate in a health plan and refuses to
accept insurance allo%able as payment in full. In commercial plans" non1participating
providers are also called &4ut1of1<et%ork $roviders' or &4ut of $lan $roviders'.
E5PLANATION OF BENEFITS
=4; is a statement from a payor generally sent to a provider and0or a patient denoting
payments or denials to the provider and any applicable patient responsibility Aeductible"
)o1insurance" and )o1payment!. Sometimes depicts services and procedures not covered
under patients policy. =xplanation of benefits is also called F2emittance Advice 2A!.
TIMELY FILIN* LIMIT
#he time frame that payor gives to the provider to submit the claims and get reimbursed.
#imely filing limit starts from date of service in case of outpatient claims and from date
of discharge in case of inpatient claims.
APPROVED AMOUNT
A reimbursement method in %hich a payor only pays a fixed amount per serviceE
ho%ever" providers cannot seek patient contributions for charges that exceed approved
amounts.
Approved Amount O Insurance $ayment M $atient 2esponsibility O #otal )harges 1
)ontractual Ad(ustment.
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CONTRACTUAL AD9USTMENT
#he difference bet%een total0actual charges and the amount of money approved by the
insurance company third1party payor!. #he payment amount is established based on the
agreements bet%een provider and payor allo%ing for discounts and0or reduced rates.
)ontractual Ad(ustment is also called F)ontractual Allo%ance" F$roviders 3rite1off" or
F$roviders Aiscount.
WRITE-OFF
Aespite all the efforts provider %as not able to reali*e cash from insurance company for
the claims or charges" %hich %ere denied. #hese claims or charges need to be %ritten off
as the denial is due to providers fault0mistake.
)laim denied for no authori*ation and insurance does not provide retro1authori*ation..
+aximum of three appeals can be sent after %hich the claim or charge needs to be %ritten
off as it %as providers fault not to obtain authori*ation.
PRE-CERTIFICATION
A reimbursement re:uirement of some payors %hereby a patients care must first be
approved by the patients payor before services %ill be rendered. +ethod of controlling
and monitoring utili*ation by evaluating the need for service prior to the service being
rendered. An administrative procedure %here third party administers medical necessity
and treatment plan.
CO-ORDINATION OF BENEFITS
#he payment of insurance benefits %hen more than one policy is involved to meet the
needs of the insured. A method of integrating benefits payable %hen there is more than
one group insurance plan so that the insureds benefits and the payment of insurance
benefits from all sources do not exceed 1-- percent of the allo%ed medical expenses.
CARVE-OUTS
A reimbursement method %hereby certain medical services are separated from payment
arrangement and paid differentlyE providers usually carve out expensive services. =xtra
payment that an institution obtains in addition to the main payment.
H+4 plan negotiates %ith a pediatrician to provide primary care services" such as office
visits and basic labs" at a capitated rate. Ho%ever" the physician negotiates carve1out for
vaccinations0immuni*ations.
NATIONAL PROVIDER IDENTIFIER 1NPI2
)enter for +edicare and +edicaid Services need to have a control over the entry of
providers0suppliers into +edicare program and so <$I is assigned. It also facilitates
specific ongoing periodic monitoring of claims and other criteria to ensure that all
providers or suppliers continue to meet re:uirements.
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EMPLOYER IDENTIFICATION NUMBER 1EIN2) #his is a tax identification
number #AJ IA! of the group into %hich the doctor has (oined. #he I2S for the purpose
of submitting the tax returns allots this number. #he group needs to sho% this number in
all claim forms and correspondence %ith the carrier.
W-: F&!m 8 #his is a &2e:uest for tax payer identification number and certification'
form. #his sho%s the providers individual tax id P SS<! or the group tax id P =I<!
along %ith the pay1to address. #his can be used for updating the tax id P and the pay1to
address %ith the carriers. #he provider should sign this.
;<:: F&!m 8 #his is a form of identification to the government that the physician is not an
employee but a contracted physician. #he physician is responsible for paying his o%n
taxes" retirement benefits etc.
C!e(en+ialin-) #he process of obtaining" verifying" and assessing the :ualifications of a
health care practitioner to provide patient care services in or for a health care
organi*ation. )redentialing is the process by %hich a health plan evaluates and approves
or disapproves a provider %ho is licensed" certified or registered to practice
independently to provide services as a participating provider of the plan.
W0e!e +& *e+ M&!e In&!ma+i&n?
+ore about +edicare and +edicaid is available in %%%.cms.gov
About o
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%%%.usps.com 1Gnited States $ostal Services Info about $ostal addresses!
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%%%.medilexicon.com1 +edical abbreviations and #itles
Apollo Health Street Ltd 1/