Glossary of Reimbursement Terms
ACHC:Â Accreditation Commission for Health Care (ACHC) is a non-profit healthcare accreditation organization focused on the needs of small providers like Cala.
Appeal:Â What is an Appeal? Appealing means asking an insurance or health benefits organization to reconsider its decision to deny paying for a therapy or service. All patients have theÂ right to appeal a denied claim, usually up to six months, and Cala Customer Care assists patients with this process through the Affordable Access services.
Cala Customer Care:Â Cala Customer Care is a dedicated support team that offers 1:1 patient assistance with health benefit claims, processing of the claim, and product training. Calaâ€™s immediate goal is to support wide policy adoption of Cala Trio therapy, allowing for all patients to experience positive and meaningful tremor relief.
Campaign for Coverage initiative:Â Campaign for Coverage is a grassroots initiative designed to educate healthcare plan administrators by receiving personal letters from essential tremor (ET) patients and their clinicians’ experiences to raise awareness and incite positive change.
Case-by-case basis:Â When an insurance company has not yet adopted a local or national coverage determination policy for a therapy treatment or medical device, they will review the insurance or health benefit claim on an individual or single, case-by-case review.
Coding (ICD-10, HCPCS, etc.):Â Health benefits plans, medical billing companies, and healthcare providers use different codes for processing and paying claims. Using the correct codes is essential to avoid billing errors.
ICD-10 G25.0 Essential Tremor. Cala Trio therapy is currently indicated for adults diagnosed with essential tremor.
K1018: â€śExternal Upper Limb Tremor Stimulator of the Peripheral Nerves of the Wrist.â€ť This covers the stimulator and base station.
K1019: â€śReplacement Supplies and Accessories for External Upper Limb Tremor Stimulator of the Peripheral Nerves of the Wrist.â€ť This covers the monthly band subscription supplied every 90 days.
Commercial insurance coverage:Â Commercial insurance plans can also be referred to as private insurance policies. These policies can be offered through one’s employer or purchased individually or as a family plan. Patients, 65 years and older and eligible for Medicare can participate in Medicare Advantage C commercial plan, which will replace traditional fee-for-service Medicare benefits.
Consultation:Â A consultation is generated by meeting with the patient and their healthcare provider, followed by a report of findings to the referring physician.
Copayment (copay):Â A form of medical cost sharing in a health benefit plan that requires an insured person to pay a fixed amount when a medical service is received. The insured person is responsible for the rest of the copay or the cost of the treatment.
Deductible:Â A fixed dollar amount during the benefit period an insured person pays before the insurer makes payments for covered medical services. Plans may have both deductibles for individuals and family deductibles. Some plans may have separate deductibles for specific services.
Denial:Â An insurance or benefit denial is when the insurance administrator determines they will not approve the prior authorization request to pay for medical treatment or medication. Cala Customer Care helps patients and healthcare providers with the prior authorization process, including proper coding, submitting the medical records that support Medical Necessity, and providing the supporting clinical evidence to minimize the chance of denial. These services are available to the patient at no charge whatsoever.
DME:Â Means â€śDurable Medical Equipment,â€ť and Cala is a Durable Medical Equipment provider and maintains accreditation through the ACHC (Accreditation Commission for Health Care).
In-Network provider:Â â€śIn-networkâ€ť Cala Trio therapy means that the treatment is contracted with the insurer to be part of their preferred provider network, and the provider will cover the cost if you meet certain clinical criteria. Some providers have coverage and network limitations and exclusions. We recommend you call your provider directly to confirm what they will pay and what they expect you will pay, and learn if any special requirements are needed before you begin your Cala Trio therapy.
Medicaid:Â Medicaid is a combination of state and federally-funded health insurance programs that provide coverage to adults who qualify as low-income and their dependents.
Medical Necessity Documentation:Â Medical Necessity documentation supports your healthcare provider’s prescribed treatment for a diagnosed medical condition that meets an acceptable standard of medical practice. This documentation is instrumental when submitting prior authorizations to insurance or health benefits organizations.
Medicare:Â Medicare is the federal health insurance or health benefits program for people 65 and older and is available to certain younger people with disabilities and end-stage renal disease. The different parts of Medicare help cover specific services:
Medicare Part A: Hospital Insurance that covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B: Medical Insurance covers certain doctor’s services, outpatient care, durable medical equipment (DME), medical supplies, and preventive services.
Medicare Part D (prescription drug coverage)
Helps cover the cost of prescription drugs (including many recommended shots or vaccines).
Medicare Advantage (or Medicare C) is a Medicare-approved plan offered by a private company that provides an alternative to original Medicare for your health and drug coverage. These â€śbundledâ€ť plans include Part A, Part B, and usually, Part D. Plans may offer some extra benefits that Part B Medicare doesnâ€™t cover â€” like vision, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicareâ€™s coverage rules. The plan must notify you about any changes before the start of the next enrollment year.
Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you access services.
Patient Access:Â Cala is committed to ensuring all patients have access to Cala Trio therapy. The Cala Customer Care team helps patients with
- Benefit verification
- Prior authorization if necessary
- Collecting Medical Necessity documentation working directly with healthcare providers.
- Appeals in the event coverage is denied at no cost to the patient.
Patient Advocate:Â A patient advocate is an individual or a group of people who share a common experience and want to enlighten others about their journey. Cala is in the process of developing a Campaign for Coverage. In this case, those diagnosed with essential tremor and who have experienced firsthand the benefits of Cala Trio therapy are engaged in a letter-writing campaign. There are many opportunities to get involved, and if you are interested, please contact us to learn more:
CustomerSuccess@CalaTrio.comÂ 888-699-1009, [Monday-Friday from 8 am â€“ 7 pm Eastern, 5 am â€“ 4 pm Pacific.
Patient Agreement:Â Patient Intake Form & Agreement collects patient and benefits information and the approval to allow Cala to assist with insurance preauthorization and obtain financial agreement from the patient and their responsibility.
Payor:Â A payor, or payer, is an organization that pays for an administered medical service. An insurance organization is the most common type of payor. A payer is responsible for processing patient eligibility, enrollment, claims, and payment.
Policy:Â A coverage policy and/or treatment guideline is a document established by a medical insurance organization to help determine which patients are eligible for specific medical services or therapies.
LCD and NCD coverage policies:Â Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) are issued by Medicare contractors. These sometimes indicate when a procedure, medical device, or medical condition will be covered.
PPO (Preferred Provider Organization) plan:Â PPO An indemnity plan, sometimes referred to as a fee-for-service plan, provides participants with coverage through a network of selected healthcare providers (such as hospitals and physicians). The enrollees may go outside the network but may incur higher costs in the form of higher deductibles or copayments.
Prior authorization:Â Although not a guarantee of benefits, a prior authorization received by Cala from your insurance benefits organization is a very good indicator that Cala Trio therapy will be covered and paid for by your insurer.
Prescription:Â A healthcare provider’s formal request for their patientsâ€™ to acquire a therapy, drug, or device.
Private insurance benefit coverage:Â Private insurance plans can also be referred to as commercial insurance. These policies are offered through one’s employer or can be purchased individually or as a family plan.
Patients 65 years and older and eligible for Medicare can participate in Medicare Advantage Part C, a private commercial plan which replaces Original Medicare Part B coverage benefits.
Reimbursement:Â a term used to describe payments for healthcare services (office visits, procedures, hospital care), medications, and devices.
TAPS Therapy:Â Transcutaneous Afferent Patterned Stimulation (TAPS). TAPS therapy consists of bursts of non-invasive electrical stimulation alternating between the median and radial nerves at the wrist at a frequency tuned to an individual patientâ€™s tremor.
MKG-1533 Rev C Oct 2022