Provider Concepts

Provider:

Anyone who gives Medical Services to a patient can be terminated as a provider. Doctors are known as provider.

Types of Providers

Participating Provider:

A provider who enters into a contract with the insurance company.

Participation Agreement:

A participating provider cannot claim anything more than the allowed amount of the insurance, either from the Insurance Company.

So, here contractual Adjustment = $ (100.00 - 80.00) = $ 20.00

Non-Participating Provider:

A provider who does not enter into a contract with the Insurance Company.

Non-Participation Agreement (Example):

So, here Balance billing or Total Patient Responsibility is $ 20.00 + (100.00-60.00) = $ 60.00

** A non-participating provider cannot bill more than 115% of Medicare's Allowed Amount. i., e., A Non-participating provider provider cannot bill more than 15% of the participating Providr's Bill. This phenomenon is called as Limiting Charge.

*** Billed Amount - Allowed Amount in case of Participating Provider = Contractual Adjustment

*** Billed Amount - Allowed Amount in case of Non-Participating Provider = Balance Billing / Write-off

Types of Providers

Referring Provider:

Referring provider is the one who refers the Patient to another Provider who is normally a Specialist.

Ordering Provider:

Ordering Provider is the one who advices the Patient to take some kind of tests like X-rays, Blood Test etc.

Attending/Rendering/Servicing/Treating Provider:

Attending Provider is the one who provides the actual treatment to the Patient.

**   A provider can be any of the above categories.

*** Locum Tenen = Substitute Provider

Provider Identifiers

1. NPI: National Provider Identifier

Assigned to both Participating & Non-participating providers to bill any Insurance Company in the U.S. & it is mandatory.

Format: 10 Digit Numeric.

Assigned by: CMS (Centers for Medicare & Medicaid Services) & Controlled by HIPAA (Health Insurance Portability and Accountability Act)

2. TIN: Tax Identification Number

Assigned to all Tax Payers.

Format: 9 Digit Numeric

Assigned by: IRS (Internal Revenue Service)

Referral Authorization: 

Authorization a patient to meet the Specialist is termed as Referral Authorization. It is given by the Referring Provider to the patient.

Prior Authorization:

A prior approval which the provider needs to get from insurance company of the patient, before performing any costly or complicated service. It is given by the insurance to the provider. The providers has to get the RETRO Authorization in case of Emergency cases & it should be received within 72 hrs.

Credentialing:

It is the provider enrollment process. It is where the Insurance checks the Provider degree certification details to confirm whether he is a qualified provider.

Facility Address:

It denotes the location where the actual treatment is rendered to the Patient (Hospital Address, Clinic, Laboratory etc).

Billing Address:

It is where the provider wants his checks and EOBs to be sent from the Insurance.

PTAN (Provider Transaction Account Number):

Each provider or supplier is assigned with unique transaction account number which was provided by Medicare. NPI need to be mentioned in claim form, where the PTAN is directly linked with NPI.

Taxonomy Code:

It is a code assigned to the provider to identify that the provider on which he or she was specialized on. It is consist with ten numeric with one alpha code. Example: 123456789X, 123P456789 etc.