CH.3&4 (Part 2 Ch. 4) Flashcards
account receivable agin report
shows the status (by date) of outstanding claims from each payer, as well as payments due to pTs.
allowed charges
the max amount the payer will reimburse for each procedure or svc, according to the pT’s policy.
ANI ASC X12N
An electronic format standard that uses a variable-length file format to process transactions for institutinal, pro, dental, and drug claims.
appeal
documented as a latter and signed by the provider, to explain why a claim should be reocnsiderd for payment.
bad debt
accounts receivable that cannot be collected by the provider or a collecton agency.
beneficiary
the person eligible to receive health care benefits.
claims adjudication
comparing a claim to payer edits and the pT’s health plan benefits to verify that required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures perfomred and svc provided are covered benefits.
claims adjustment reason codes (CARC)
reason for denial claim as reported on the remittance advice or explanation of benefits.
claims attachment
medical report substaining a medical condition.
claims management
completion, submission, and follow-up of claims for procedures and svcs provided.
claims processing
sorting claims upon submission to collect and verify information about the pT and provider.
claims submission
the transaction of claims data (electronically or manually) to payers or clearinghouses for processing
clean claim
a correctly completed standardized claim (e.g. CMS-1500 claim)
clearinghouse
agency or organization that collects, process, and distributes health cre claims after editing and validating them to ensure that they are error-free, reforming them to the payer’s specifications, and submitting them electronically to appropriate payer for further processsing to generate reimbursement to the provider.
closed claims
claims for which all processing, includes appeals, has been completed.
common data file
summary abstratc report of all recent claims filed on each pT.
coordination of benefits (COB)
provision in group health insurance plocies that prevents multiple insures from paying benefits covered by other polocies; also specifies taht coverage in a certain sequenc when more than one policy covers the claim.
covered entities
private sector health plans, managed care organizations, govt health plans, all health care cleairnghouses; and all health care providers that choose to submit or receive transactions electronically.
delinquet account
AKA: past due account
delinquent claims
claims usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due.
delinquet claim cycle
advances through various aging periods, with practices typically focusing internal recovery efforts on older delinquet accounts
denied claims
claim returned to the provider by payers due to coding erros, missing info, and pT coverage issues.
downcoding
assigned lower-level codes than documented in the record.
electronic data interchange (EDI)
computer to computer exchange of data between provider and payer.
electronic flat file format
series of fixed-length records (e.g. 25 spaces for pT’s name) submitting to payers to bill for health care services.
electronic funds transfer
(EFT)
system by which payers electronically deposit funds to the provider’s (bank) account.
electronic media claim
AKA: electronic flat file format
electronic remittance advice (ERA)
remittance advice that is submitted by the third party payer to the provider electronically and contains the same info as a paper-based remittance advice; providers receive the ERA more quickly.
explanation of benefits (EOB)
document sent to the pT by insc Co that provides details about pT financial responsibilities, payer schedule, claims, and provider charges.
fragmentation
AKA: unbundling
litigation
legal action to recover a debt; usually a last resrot for a medical practice.
Medicare Remitatnce Advice
an electronic remittance advice (ERA) or standard paper remit (SPR) sent to providers by Medicare administrative contractors, which contain details about claims adjudication, payments, deductables, refunds, incorrect data, etc and so on.
Doumentation sent to providers from Medicare that explain thier contarct
noncoverd benefit
any procedure or service that is not covered on a pT’s insc. can result in a claim denial or financially responsible for pT to cover out of pocket.
open claims
submitted to the payer, but processing is not complete.
outsource
contract out
past-due account
a bil that has not been paid in a certain time framed as negotiated
AKA: delinquet account
peer review
appeal process that involves review of aby a medical reviewer, nurse, or med director. if an appeal is escalated an external review may assess the appeal
pre-exsisting condition
any medical condition that was diagnosed/treated within a time frame before the enrollee’s effective date of coverage.
remit
AKAL remitatnce advice
remittance advice
sen to providers from insc Co stating their financial guidles and rules when contracted under agreement with a certain Co or agency
remittance advice remark codes
additional explanation of reasons for denied claims
skip tracing
practice of locating pT’s to obtain payment of a bad debt; uses credit reports, dtabases, criminal backgroun checks, and other methods.
skip tracking
AKA: skip tracing
source document
the routing slip, charge slip, encounter form, pr superbill from which the insc claim was generated.
suspense
AKA: pending
unassigned claims
generated for providers who do not accept assignment; organized by year.
unauthorized services
svcs that are provided to a pT w/out proper pre-auth or that are not covered by a current preauth.
unbundling
submitted multiple CPT codes when one code should be submitted.
