To estimate the costs for a healthcare service with a healthcare provider, you will need the following key pieces of information:
- Tax ID of Billing Provider: This unique identification number, assigned by the IRS, ensures that the billing and cost estimation are accurately linked to the correct provider.
- CPT Code for Service Performed: For an office visit, common CPT codes include:
- 99213: Established Patient
- This code is used for an office or other outpatient visit for the evaluation and management of an established patient. It includes components and complexity necessary for such visits.
- 99214: Established Patient
- This code is for an office or other outpatient visit for the evaluation and management of an established patient, involving a higher level of complexity compared to 99213.
- 99203: New Patient
- This code is used for an office or other outpatient visit for the evaluation and management of a new patient, covering all necessary components for a new patient visit.
- Billed Amount from Provider: This is the amount that the healthcare provider charges for the office visit. Knowing this figure is crucial as it represents the initial charge before any insurance adjustments, co-pays, or discounts are applied.
By gathering the Tax ID of the billing provider, the appropriate CPT code, and the billed amount, you will have the necessary information that the claims department needs to look up costs.
The Tax ID ensures the claim is attributed to the correct provider, the CPT code specifies the exact service provided, and the billed amount indicates the provider’s charge for the service. Insurance companies use these details to determine the allowable amount, calculate patient responsibility, and process reimbursements, ensuring accurate billing for both the provider and the patient based on agreed-upon rates and coverage policies.
You can learn more about CPT codes at the AMA website.