Chapter 4 Flashcards
accept assignment
provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).
accounts receivable
the amount owed to a business for services or goods provided.
accounts receivable aging report
shows the status (by date) of outstanding claims from each payer, as well as payments due from patients.
accounts receivable management
assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verification/eligibility and preauthorization of services.
allowed charges
the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy.
ANSI ASC X12N
an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims.
appeal
documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment.
assignment of benefits
the provider receives reimbursement directly from the payer.
bad debt
accounts receivable that cannot be collected by the provider or a collection agenc
beneficiary
the person eligible to receive health care benefits.
birthday rule
determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
case management
development of patient care plans to coordinate and provide care for complicated cases in a cost-effective manner.
charge description master (CDM)
see chargemaster.
chargemaster
document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility’s patient accounting system, and charges are automatically posted to the patient’s bill (UB-04).
chargemaster maintenance
process of updating and revising key elements of the chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.
chargemaster team
team of representatives from a variety of departments who jointly share responsibility for updating and revising the chargemaster to ensure accuracy.
claims adjudication
comparing a claim to payer edits and the patient’s health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicate; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.
claims adjustment reason code (CARC)
reason for denied claim as reported on the remittance advice or explanation of benefits.
claims attachment
medical report substantiating a medical condition.
claims denial
unpaid claim returned by third-party payers because of beneficiary identification errors, coding errors, diagnosis that does not support medical necessity of procedure/service, duplicate claims, global days of surgery E/M coverage issue, NCCI edits, and other patient coverage issues (e.g., procedure or service required preauthorization, procedure is not included in patient’s health plan contract, such as cosmetic surgery).
claims processing
sorting claims upon submission to collect and verify information about the patient and provider.
claims rejection
unpaid claim returned by third-party payers because it fails to meet certain data requirements, such as missing data (e.g., patient name, policy number); rejected claims can be corrected and resubmitted for processing.
claims submission
the transmission 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, processes, and distributes health care claims after editing and validating them to ensure that they are error-free, reformatting them to the payer’s specifications, and submitting them electronically to the appropriate payer for further processing to generate reimbursement to the provider.
closed claim
claims for which all processing, including appeals, has been completed.
coinsurance
2nd insurance
common data file
abstract of all recent claims filed on each patient.
concurrent review
review for medical necessity of tests and procedures ordered during an inpatient hospitalization.
Consumer Credit Protection Act of 1968
was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges, compare costs, and shop for the best credit deal.
coordination of benefits (COB)
provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.
covered entity
private sector health plans (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans (Employee Retirement Income Security Act of 1974), and government health plans (including Medicare, Medicaid, Military Health System for active duty and civilian personnel; Veterans Health Administration, and Indian Health Service programs); all health care clearinghouses; and all health care providers that choose to submit or receive transactions electronically.
data analytics
tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.
data mining
extracting and analyzing data to identify patterns, whether predictable or unpredictable.
data warehouse
database that use reporting interfaces to consolidate multiple databases, allowing reports to be generated from a single request; data is accumulated from a wide range of sources within an organization and is used to guide management decisions.
day sheet
also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.
deductible
amount paid out of pocket
delinquent account
see past due account.
delinquent claim
claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due.
delinquent claim cycle
advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (e.g., 120 days or more).
