chapter 4 revenue cycle management Flashcards
ACCEPT ASSIGNMENT
PROVIDER ACCEPTS ASA PAYMENT IN FULL WHATEVER IS PAID ON THE CLAIM BY THE PAYER
ACCOOUNTS RECEIVABLE
THE AMOUNT OWED TO A BUSINESS FOR SERVICES OR GOODS PROVIDED
ACCOUNT RECEIVABLE AGING REPORT
SHOWS THE STAUS OF OUTSTANDING CLAIMS FROM EACH PAYER AS WELL AS PAYMENTS DUE FROM PATIENTS
ACCOUNTS RECEIVABLE MANAGEMENT
ASSUSTS PROVIDERS IN THE COLLECTION OMF APPROPRIATE REIMBURSEMENT FOR SERVIES RENDERED
ALLOWED CHARGES
MAXIMUM AMOUNT THE PAYER WILL REIMBYRSE FOR EACH PROCEDURE OR SERVICE ACCORDING TO THE PATIENTS POLICY
APPEAL
DOCUMENTED AS A LETTER SIGNED BY THE PROVIDER EXPLAINING WHY A CLAIM SHOULD BE RECONSIDERED FOR PAYMENT
ANSI ASC X12N
AN ELECTRONIC FORMAT STANDAR4D THAT USES A VARIABLE LENGTH FILE FORMAT TO PROCCESS TRANSACTIONS FOR INSTITUTIONAL PROFESSIONAL DENTAL AND DRUG CLAIMS
BAD DEBT
ACCOUNTS RECEIVABLE THAT CANNOT BE COLLECTED BY THE PROVIDER OR A COLLECTION AGENCY
ASSIGNMENT OF BENEFITS
THE ORIVIDER RECIVES REIMBURSSEMENT DIRECTLY FROM TEH PAYER
BENEFICIARY
PERSON ELIGIBLE TO RECEIVE HEALTH CARE BENEFITS
BIRTHDAY RULE
DETERMINES COVERAGE BY PROMARY AND SECONDARY POLICIES WHEN EACH PARENT SUBSCRIBES TO A DIFFERENT HEALTH INSURANCE PLAN
CASE MANAGEMENT
DEVELOPMENT OF PATIENT CARE PLANS T COORDINATE AND PROVIDE CARE FOR COMPLICATED CASES IN A COST EFFECTIVE MANNER
CHARE DESCRIPTION MASTER CDM
CHARGEMASTER
CHARGEMASTER
DOCUMENT THAT CONTAINS A COMPUTER GENERATED LIST OF PROCEDURES SERVICES AND SUPPLIES WITH CHARGES FOR EACH CHARGEMASTER DATA ARE ENTERED IN THE FACILITYS PATIENT ACCOUNTING SYSTEM, AND CHARGES ARE AUTOMATICALLYH POSTED TO TEH PATIENTS BILL UB-04
CHARGEMASTER MAINTENANCE
PROCESS OF UPDATING AND REVISING KEY ELEMENTS OF THE CHARGEMASTER TO ENSURE ACCURATE REIMBURSEMENT
CHARGEMASTER TEAM
TEAM OF REPRESENTATIVES FROM A VARIETY OF DEPARTMENTS WHO JOINTLY SHARE RESPONSIBILITY FOR UPDATING AND REVISING THE CHAREGEMASTER TO ENSURE ACCURACY
CLAIMS ADJUDICATION
COMPARING A CLAIM TO PAYER EDUTS THE PATIENTS HEALTH PLAN BENEFITS TO VERIFY THA TEH REQUIRED INFORMATION IS AVAILABLE TO PROCESS TEH CLAIM
CLAIMS ADJUSTMENT REASON CODE CARC
REASON FOR DENIED CLAIM AS REPORTED ON THE REMITTANCE ADVICE OR EOB
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 DOSE NOT SUPPOR TMEDICAL NECCESSITY
CLAIMS PROCESSING
SORTING CLAINS UPON SUBMISSION TO COLLECT AND VERIFY INFORMATION ABOUT THE PATIENT AND PROVIDER
CLAIMS REJECTION
UNPAID CLAIM RETURNE DBY THIRD PARTY PAYERS BECAUSE IT FAILS TO MEET CERTAIN DATA REQUIREMENTS SUCH AS MISSING DATA
CLAIMS SUBMISSION
THE TRANSMISSON OF CLAIMS DATA TO PAYERS OR CLEARINGHOUSES FOR PROCCESSING
CLEAN CLAIM
CORRECTLY COMOLETED STANDARDIZED CLAIM
CLEARINGHOUSE
AGENCY OR ORGANIZATION THAT COLLECTS PROCESSES AND DISTRIBUTS HEALTH CARE CLAIMS AFTER EDITING AND VALIDATING THEM TO ENSURE THAT THEY ARE ERROR FREEE
CLOSED CLAIM
CLAIMS FOR WHICH ALL PROCESSING INCLUDING APPEALS HAS BEEN COMPLETED
COINSURANCE
ALSO CALLE DCOINSURANCED PAYMENT THE PERCENTAGE THE PATIENT PAYS FOR COVERED SERVICES AFTER THE DEDUCTIBLE HAS BEEN MET AND THE COPAYMENT HAS BEEN PAID
COMMON DATA FILE
ABSTRACT OF ALL RECENT CLAIMS FILED ON EACH PATIENT
CONCURRENT REVIEW
REVIEW FOR MEDICAL NECCESSITY OF TEST AND PROCEDURES ORDERED DURING AN INPATIENT HOSPITALIZATION
CONSUMER CREDIT PROTECTION ACT OF 1968`
WAS CONSIDERED LANDMARK LEGISLATION BECAUSE IT LAUNCHED TRUTH IN LENDING DISCLOSURED THAT REQUIRED CREDITORS TO COMMUNICATE THE COST OF BORRIWUBG MONEY IN A COMMON LANGUAGE SO HA TCONSUMERS COULD FIGURE OUT THE CHARGES COMPARE COST AND SHOP FOR THE BEST CREDIT DEAL
COORDINATION OF BENEFITS COB
PROVISION IN GROUP HEALTH INSURANCE POLICIES THAT PREVENTS MULTIPLE INSURERS FROM PAYING BEEFITS COVERED BY OTHER POLICIES
COVERED ENTITY
PRIVATE SECTOR HEALTH PLANS MANAGED CARE ORGANIZATIONS COVERD HEALTH BEEFIT PLANS AND GOVERNMENT HEALTH PLANS
DATA ANALYTICS
TOOLS AND SYSTEMS THAT ARE USED OT ANALYZE CLINICLA AND FINANCIAL DATA
DATA MINING
EXTRACTING AND ANALYZING DATA TO IDENTIFY PATTERNS
DATA WAREHOUSE
DATABASE THAT USE REPORTIN GINTERFACES TO CONSIOLIDATE MUTIPLE DATABASES ALLOWING REPORTS TO BE GENERATED FORM A SINGLE REQUEST
DAY SHEET
ACCOUNTS RECEIVABLE JOURNAL CHRONOLGIVALO SUMMARY OF ALL TRANSACTIONS POSTED TO INDIVIDUAL PATIENT LEDGERS ACCOUNTS ON A SPECIFIC DAY
DEDUCTIBLE
AMOUNT FOR WHICH THE PATIENT IS FINACIALLY RESPONSIBLE BEFORE AN INSURANCE POLICY PROVIDES COVERAGE
DELINQUENT ACCOUNT
PAST DUE ACCOUNT
DELINQUENT CLAIM
CLAIM USUALLY MARE THAN 120 DAYS PAST DUE
DELINQUENT CLAIM CYCLE
ADVANCE THROUGH VARIOUS AGING PERIODS WITH PRACTICES TYPICALLY FOCUSING INTERNAL RECOVERY EFFORTS ON OLDER DELINQUENT ACCOUNTS
DENINED CLAIM
CLAIM RETURNED TO THE PROVIDER BY PAYERS DUE TO CODING ERRORS
DISCHARGE PLANNING
INCOLVES ARRANGING APPROPRIATE HEALHT CARE SERVICES FOR THE DISCHARGED PATIENT
DOWNCODING
ASSIGNING 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 FIXE DLENGTH RECORDS
ELECTRONIC FUNDS TRANSFER EFT
SYSTEM BY WHICH PAYERS DEPOSIT FUNDS TO THE PROVIDERS ACCOUNT ELECTRONICALLY
ELECTRONIC FUNDS TRANSFER ACT
ESTABLISHED THE RIGHTS LIABILITIES AND RESPONSIBILITIES OF PARTICIPANTS IN ELECTRONIC FUNDS TRANSFER SYSTEM
ELECTRONIC HEALTHCARE NETWORK ACCREDITATION COMMISSON EHNAC
ORGANIZATION THAT ACCREDITS CLEARINGHOUSES
ELECTRONIC MEDIA CLAIM
ELECTRONIC FLAT FILE FORMAT
ELECTRONIC REMITTANCE ADVICE ERA
REMITTANCE ADVICE THAT IS SUBMITTED TO ATHE PROVIDER ELECTRONICALLLY AND CONTAINS THE SAME INFORMATION AS A PAPER BASE DREMITTANCE ADVICE
ENCOUNTER FORM
FINANCIAL RECORD SOURCE DOCUMENT USED BY PROVIDERS AND OTHER PERSONNEL TO RECORD TREATED DIAGNOSES AND SERVICES RENDERED TO TEH PATIENT DURING THE CURRENT ENCOUNTER
EQUAL CREDIT OPPORTUNITY ACT
PROHIBITS DISCTIMINATION ON THE BASIC OF RACE COLOR RELIGION NATHIONAL ORIGIN SEX MARITAL STATUS AGE
FAIR CREDIT AND CHAREGE CARD DISCLOSURE ACT
AMENDED THE TRUTH IN LENDING ACT REQUIRUNG CREDIT AND CHAREG CARD ISSURES TO PROVIDE CERTAIN DISCLOSURES IN DIRECT MAIL TELEPHONE
FAOR CREDIT BILLING ACT
THAT HELPS CONSUMERS RESOLVE BILLING ISSUES WITH CARD ISSUERS PROTECTS IMPORTANT CREDIT RIGHTS
FAIR CREDIT REPORTING ACT
PROTECTS INFORMATION COLLEFCTED BY CONSUMER REPORTING AGENCIE SSUCH AS CREDIT DUREAUS
FAIR DEBT COLLECTION P0RACTICES ACT FDCPA
SPECIFIES WHAT A COLLECTION SOURCE MAY AND MAY NOT DO WHEN PURSURING PAYMENT OF PAST DUE ACCOUNTS
GUARANTOR
PEROSON RESPONSIBLE FOR PAYING HEALTH CARE FEES
INTEGRATED REVENUE CYCLE IRC
COMBINING REEVENUE CYLCE MANAGEMENT WITH CLINICAK CODING AND INFORMATION MANAGEMENT DECISIONS BECAUSE OF THE IMPACT ON FINANCIAL MANAGEMENT
LITITGATION
LEGAL ACTION TO RECOVER A DEBT
MANUAL DAILY ACCOUNTS RECEIVABLE JOURNAL
CHRONOLOGICAL SUMMARY OF ALL TRANSACTIONS POSTED TO INDIVIDUAL PATIENT LEDGERS ON A SPECIFIC DAY
METRICS
STANDARDS OF MEASUREMENT
NONCOVVERED BENEFIT
ANY PROCEDURE OR SERVICE REPORTED ON A CLAIM THAT IS NOT INCLUDED ON THE PAYERS MASTER BENEFIT LIST
NONPARTICIPATING PROVIDER NONPAR
DOSE NOT CONTRACT WITH THE INSURANCE PLAN PLATIENTS WHO ELECT TO RECIEVE CARE FORM NON PARS WILL HIGHER OUT OF POCKET EXPWNSES
OPEN CLAIM
SUBMITTED TO THE PAYER BUT PROCESSING IS NOT COMPLETE
OUT OF POCKET PAYMENT
ESTABLISHED BY HEALTH INSURANCE SOMPAINS FOR A HEALTH INSURANCE PLAN
OUTSOURCE
CONTRACT OUT
PARTICIPATING PROVIDER PAR
CONTACTS WITH A HEALTH INSURANE PLAN AND ACCEPTS WHATEVER THE PLAN PAYS FOR PROCEDURES OR SERVICES PERFORMEND
PAST SURE ACCOUNT
ONE THAT HAS NOT BEEN PAID WITHIN A CERTAIN TIME FRAME
PATIENT ACCOUNT RECORD
A COMPUTERIZED PERMANENT RECORD OF ALLL FINANICIAL TRANSACTIONS BETWEEN THE PATIENT AND THE PRACTICE
PATIENT LEDGER
PATIENT ACCOUNG RECORD
PREDADMISSION CERTIFICATION
REVIEW FOR MEDICAL NECCESSITY OF INPATIENT CARE PRIOR TO THE PATIENTS ADMISSION
PREDADMISSION REVIEW
PREADMISSION CERTIFICATION
