RCM: 15 Day Terminology to Know Flashcards
Accounts Receivable Reports
Shows payments billed but not paid by month or quarter and by payer and/or service delivery site.
Allowances and Adjustments
Allowances are an adjustment made to gross charges based on the contractual amount a practice is paid by each insurance company for the service or supply charged on a bill. Also called a “contractual allowance”, the practice of applying allowances to the accounts receivable (see definition) adjusts the amount projected for collection by the service provider so that staff can accurately monitor revenue received compared to adjusted charges.
Capitation Payments
Traditionally used by HMOs and other managed care organizations, capitation payments are monthly payments made by insurers to primary care providers for patients assigned to/enrolled in their care.
Chargemaster or Charge Description Master (CDM)
A table consisting of all visit types and procedures and items a practice offers/uses. It includes a description of the activity or item, a CPT or HCPCS code and a dollar amount that is considered the “charge” for performing that service or providing that supply.
Charges
Once set in a chargemaster, charges are used in the management of the accounts receivable for the service provider. Charges are referred to as Full or Gross charges if they have not been adjusted in any way, and are the top rate billed to any patient or insurer when a fee scale or contract is not in place.
Chief Complaint
Concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the patient encounter, usually stated in the patient’s own words.
Claim
A request for payment under the terms of an insurance policy.
CMS 1500
The official standard form used by physicians and other providers when submitting bills/claims for reimbursement to Medicare or Medicaid for health services. It is also used by private insurers and managed care plans. CMS 1500 contains patient demographics, diagnostic codes, CPT/HCPCS codes, diagnosis codes, units, etc.
Coinsurance
The percentage that you must pay to share responsibility for your medical claims after you meet your annual deductible.
Co-payment
A flat fee that you must pay toward the cost of medical visits, your insurance provider pays the remaining balance.
Current Procedural Terminology (CPT)
A system developed by the American Medical Association for standardizing the terminology and coding used to describe medical services and procedures.
Deductible
The annual amount of money you must pay out of pocket for medical expenses before your insurance kicks in and starts to make payments.
Denial
Claim that is not paid by an insurance carrier. Denials can be made for many reasons: non-credentialed provider, client not insured on date of service, service not covered, prior authorization needed but not on claim, etc.
Dependent
A person for whom the insured has some legal obligation to. For most plans, it is the insured’s spouse and/or children.
Diagnosis Code (ICD-10)
Alphanumeric codes used to identify diagnoses for the purposes of computer storage. In combination with CPT codes, these are used to determine payment by Medicare, Medicaid Managed Care plans, commercial insurance plans and some Medicaid programs. (See also ICD and CPT).
Effective Date
Electronic billing occurs when claims are sent from a provider to an insurer electronically from their practice management system or a billing module within their Electronic Health Record system.
Evaluation and Management
Describes the medical visit a patient has with clinician; E/M, Medical Visit, Evaluation and Management are terms used interchangeably.
Excluded Services
Health care services that your health insurance or plan does not pay for or cover.
Explanation of Benefits (EOB)
A letter that goes to an insured person when a claim is filed with the insurance company for services. Primarily created for fraud prevention, EOBs are used consistently by some plans in some states; in other states or companies, the usage varies from random to occasional.
Health Maintenance Organization (HMO)
A health care financing and delivery system that provides comprehensive health care for subscribing members in a particular geographic area using managed care techniques.
Health Savings Account (HSA)
Plan that allows you to contribute pre-tax money to be used for qualified medical expenses.
International Statistical Classification of Diseases (ICD-10)
A coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO).
Modifier
A two-digit code that can be put on a claim next to a CPT code for the purpose of affecting the allowed payment (commonly results in an increased allowed payment).
Network
A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Out-of-Network
Health care services received outside the HMO, POS or PPO network.
Out-of-Pocket Expense
Any medical care costs not covered by insurance, which must be paid by the insured.
Patient Type
Definition of patients based on frequency of service. New patient - an individual who has NOT received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years; Existing Patient – an individual who has received a service within the last 3 years.
Premiums
The monthly or annual amount that you must pay in order to have the insurance coverage.
Prescription Drug Coverage (Rx)
A type of specified expense coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter.
Primary Care Physician (PCP)
A general or family practitioner who serves as the insured’s personal physician and first contact with a managed care system.
Primary Diagnosis
Code assigned to the diagnosis, condition, problem, or other reason shown in the documentation to be chiefly responsible for services provided.
Remittance (Paper or Electronic)
Information included with the payment from an insurer that describes what services and payments are included in the payment sent to the provider.
Renewal Date
The specified date of when the health insurance coverage will renew for another period, typically one year.
Revenue Cycle Management (RCM)
A process of reviewing and monitoring every step of the coding, billing, collection, posting and denial management processes for collecting revenue.
