Allows patients to only go to physicians, other healthcare professionals, orhospitals on a list
of approved providers, except in an emergency
6. Procedure Code
ANS ICD-9-CM, CPT, HCPCS codes that represents the procedureor service provided.
7. Modifier
ANS Additional information about types of services; part of valid CPT orHCPCS code.
8. Timely Filing Requirement
ANS Within one calendar year of the claims date ofservice.
9. Coordination of Benefits
ANS Determines which insurance plan is primary in whichis secondary.
10. Explanation of Benefits (EOB)
ANS Describes the services rendered, paymentcovered, benefit limits, and denials.
11. Crossover Claims
ANS Claim submitted by people covered by a primary and sec-ondary insurance plan, such as
Medicare and Medicaid. Medicare received the bill first, applies a deductible/coinsurance and
then automatically forwards it to Medicaid. providers no longer have to bill Medicaid
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