Medical Coding and Billing Flashcards
Submission
The healthcare provider sends the claim to the third-party payer requesting payment. Submissions are made electronically or occasionally by paper bill.
Processing
The third-party payer receives the claim and gathers information related to the case.
Adjudication
The third-party payers process of checking the details of the claim against the information they have on the patient and his or her insurance benefits. This process also checks for completeness of the claim, bundling issues for CPT codes, medical necessity, and recent claims (to avoid unnecessary service or duplicate claims).
EOB
Explanation of benefits
Reconciliation
The process the healthcare provider analyzes receive payment information compared to submit a claim information for accuracy. If the provider believe the claim was inappropriately denied by the payer the dispute process begins until satisfactory reconciliation is achieved by the provider in the third-party payer.
ABN
Advance Beneficiary Notice of Noncoverage
LCDs
Local coverage determinations
NCDs
National coverage determinations
MACs
Medicare administrative contractors
An ABN should normally be retained for _____
5 years
UB-04
Claim form used to bill inpatient and outpatient facility charges: surgery centers, freestanding radiology clinic’s, laboratories, hospitals, skilled nursing, and emergency rooms
CMS-1500
The claim form used to bill professional services: surgeons fees for surgery performed at an outpatient surgery center or an emergency physicians fee for professional services provided in the emergency room
Administrative law
Created by administrative agencies of government
Case law or common law
Based on judicial decision
Statutory law
Passed by legislative body
CFR
Code of federal regulations
HIPAA is what kind of law?
Statutory law
