Chapter 4 Flashcards
Understanding Revenue Management Cycle
Electronic Data Interchange (EDI)
computer-to-computer exchange of data between provider and payer.
Covered entities
private-sector health plans, managed care organizations, ERISA-covered health benefit plans and government health plans; all health clearinghouses; and all health care providers that choose to submit or receive transactions electronically
ANSI ASC x12N
an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental and drug claims
clean claim
a correctly completed standardized claim
claims attachment
medical report substantiating a medical condition
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
claims processing
sorting claims upon submission to collect and verify information about the patient and provider
claims adjudication
comparing a claim to payer edits and the patient’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 performed and services provided are covered benefits
noncovered benefit
any procedure or service reported on a claim that is not included on the payer’s master benefit list, resulting in denial of the claim
unauthorized services
services that are provided to a patient without proper preauthorization or that are not covered by a current preauthorization
common data file
summary abstract report of all recent claims filed on each patient
allowed charges
the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
beneficiary
the person eligible to receive health care benefits
downcoding
assigning lower-level codes than documented in the the record
upcoding
assignment of a ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement
unbundling (fragmentation)
submitting multiple CPT codes when one code should be submitted
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
electronic funds transfer (EFT)
system by which payers electronically deposit funds to the providers (bank) account
source document
the routing slip, charge slip. encounter form, or superbill from which the insurance claim was generated
open claims
submitted to the payer, but processing is not complete
closed claims
claims for which all processing, including appeals, has been completed
unassigned claims
generated for providers who do not accept assignment; organized by year
denied claims
claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues
remittance advice remark codes (RARC)
additional explanation of reasons for denied claims
claims adjustment reason codes (CARC)
reason for denied claim as reported on the remittance advice or explanation of benefits
appeal
documented as a letter and signed by the provider to explain why a claim should be reconsidered for payment
pre-existing condition
any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee’s effective date of coverage
peer review
appeal process that involves review of aby a medical reviewer or medical director, and if an appeal is escalated, an independent external reviewer may assess the appeal
past-due account (delinquent account)
one that has not been paid within a certain time frame (e.g. 120 days)
delinquent claim cycle
advances through various aging periods (30 days, 60 days, 90 days, and son on), with practices typically focusing internal recovery efforts on older delinquent accounts
delinquent claims
claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due
accounts receivable aging report
shows the status (by date) of outstanding claims from each payer, as well as payments due from patients
skip tracing (skip tracking)
practice of locating patients to obtain payment of a bad debt; uses credit reports, databases, criminal background checks and other methods
litigation
legal action to recover a debt; usually a last resort for a medical practice
