CBCS cheat sheet

Eligibility verification confirms active coverage, effective date, plan type, and patient cost-sharing before services are rendered.

Prior authorization is payer approval obtained before a specific service; missing authorization commonly causes denial.

Document the authorization number, approved units, CPT/HCPCS codes, and valid date range in the patient record.

A referral is provider-to-provider permission, often required by HMO plans; it is not the same as prior authorization.

Coordination of benefits (COB) determines primary and secondary payer; the birthday rule commonly applies to dependent children.

HIPAA X12 270/271 transactions provide real-time eligibility inquiry and response electronically.

Insurance card verification captures member ID, group number, PCP name, copays, and payer contact information.

Medicare Advantage plans may require prior authorization for services Original Medicare does not; verify plan-specific rules.

ICD-10-CM codes diagnoses; codes are 3-7 characters, begin with a letter, and may require a 7th character.

CPT Category I codes are 5-digit procedure codes; Category II are performance measures; Category III are emerging technology.

HCPCS Level II codes are alphanumeric, begin with a letter, and cover drugs, supplies, DME, and non-CPT services.

Office E/M level is selected by medical decision making or total time; history and exam no longer determine level.

Modifier 25 reports a significant, separately identifiable E/M service on the same day as a procedure.

Modifier 59 identifies a distinct procedural service and may override NCCI bundling when appropriate.

The first-listed ICD-10-CM code should reflect the reason for the service and support medical necessity.

Place of service (POS) code identifies where the service occurred (e.g., 11 office, 21 inpatient) and affects payment.

CMS-1500 is the paper claim form for professional services; UB-04 is used for institutional/facility claims.

X12 837P is the electronic professional claim; 837I is the institutional claim.

A clean claim is complete and accurate, passes edits, and needs no additional information before adjudication.

NPI is a 10-digit identifier: Type 1 for individuals, Type 2 for organizations.

Timely filing limits vary by payer, often 90-365 days; missing them can forfeit payment.

EOB is paper; ERA (835 transaction) is electronic remittance advice used for automated posting.

A rejection is not accepted for processing; a denial is processed and denied for coverage or medical necessity.

Reimbursement methods include fee-for-service, capitation, DRG, RVU-based, and bundled payments.

Revenue cycle flow: scheduling, registration, coding, charge capture, claims, payment posting, A/R follow-up, collections.

A/R days = (total accounts receivable divided by total charges) multiplied by days in the period.

Aging buckets commonly include 0-30, 31-60, 61-90, 91-120, and 120+ days.

First-pass resolution rate and clean claim rate are key revenue cycle KPIs.

Charge capture errors and charge lag increase A/R days and reduce revenue.

Contractual adjustments reflect the difference between billed charges and payer-allowed amounts.

Credit balances must be refunded or offset within payer-specified timeframes.

Denial management includes root-cause analysis, appeal, and resubmission.

HIPAA Privacy Rule governs PHI use and disclosure and permits treatment, payment, and operations without authorization.

HIPAA Security Rule requires administrative, physical, and technical safeguards for ePHI.

The minimum necessary standard limits PHI use and disclosure to the least amount needed.

Breach notification to affected individuals is required within 60 days; breaches over 500 also notify HHS and media.

The False Claims Act prohibits knowingly submitting false claims and supports qui tam relators.

The Anti-Kickback Statute prohibits remuneration to induce referrals for federal healthcare business.

Stark Law prohibits physician self-referral for designated health services paid by Medicare.

OIG compliance program elements include written policies, a compliance officer, training, auditing, and enforcement.

An Advance Beneficiary Notice (ABN) is used for non-covered services when Medicare payment may be denied.