Revenue Cycle

Question 1

Accept assignment

Answer 1

Provider accepts as payment in full whatever is paid in the claim by the payer (exception: copay and Coinsurance)

Question 2

Accounts receivable

Answer 2

The amount owed to a business for services or goods provided

Question 3

Accounts receivable aging report

Answer 3

Shows the status by date of outstanding claims from each payer, as well as payments due from patients

Question 4

Accounts receivable management

Answer 4

Assists providers in the collection of appropriate reimbursement for services rendered; including functions such as insurance verification/ eligibility and pre authorization of services

Question 5

Allowed charge

Answer 5

The maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy

Question 6

ANSI asc x12n

Answer 6

An electronic format that uses a variable- length file format to process transactions for institutional, professional, dental, and drug claims

Question 7

Appeal

Answer 7

Document as a letter, signed by the provider, explaining why the claim should be reconsidered for payment

Question 8

Assignment of benefits

Answer 8

The provider receives a reimbursement directly from the payer

Question 9

Bad debt

Answer 9

Accounts receivable that cannot be collected by the provider or a collection agency

Question 10

Beneficiary

Answer 10

The person eligible to receive health care benefits

Question 11

Birthday rule

Answer 11

Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan

Question 12

Case management

Answer 12

Development of patient care plans to coordinate and provide care for complicated cases in a cost effective manner

Question 13

Charge master

Answer 13

Document that contains a computer generated list of procedures, services, and supplies with charges for each; charge master data are entered in the facility’s patient accounting system, and charges are automatically posted to the patient’s bill (ub-04)

Question 14

Charge master maintenance

Answer 14

Process of updating and revising key elements of the charge master to ensure accurate reimbursement

Question 15

Claims adjudication

Answer 15

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

Question 16

Claims adjustment reason code

Answer 16

Reason for denied claim as reported on the remittance advice or explanation of benefits

Question 17

Claims attachment

Answer 17

Medical report substantiating a medical condition

Question 18

Claims denial

Answer 18

Unpaid claim returned by third party payer 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

Question 19

Claims processing

Answer 19

Sorting claims upon submission to collect and verify information about the patient and provider

Question 20

Claims rejection

Answer 20

Unpaid claims returned by third party payers because it fails to meet certain data requirements, such as missing data

Question 21

Claims submission

Answer 21

The transmission of claims data to payers from clearinghouses for processing

Question 22

Clean claim

Answer 22

A correctly completed standardized claim

Question 23

Clearinghouse

Answer 23

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

Question 24

Closed claim

Answer 24

Claims for which all processing, including appeals, has been completed

Question 25

Coinsurance

Answer 25

The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid

Question 26

Common data file

Answer 26

Abstract of all recent claims filed on each patient

Question 27

Concurrent review

Answer 27

Review for medical necessity of tests and procedures ordered during a in patient hospitalization

Question 28

Consumer credit protection act of 1968

Answer 28

Considered landmark legislation because it launched in 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

Question 29

Coordination of benefits

Answer 29

Provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies

Question 30

Covered entity

Answer 30

Private sector health plans, managed care organizations, Erisa health covered benefit plans, and the government health plans; all clearinghouses; all health care providers that choose to submit or receive transactions electronically

Question 31

Data analytics

Answer 31

Tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments

Question 32

Data mining

Answer 32

Extracting and analyzing data to identify patterns, whether predictable or unpredictable

Question 33

Data warehouse

Answer 33

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

Question 34

Day sheet

Answer 34

Chronological summary of all transactions posted to individual patient ledgers/ accounts on a specific day

Question 35

Deductible

Answer 35

Amount for which the patient is financially responsible before an insurance policy provides coverage

Question 36

Delinquent claim

Answer 36

Claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due

Question 37

Delinquent claim cycle

Answer 37

Advances through various aging periods; with practices typically focusing internal recovery efforts on older delinquent accounts

Question 38

Denied claim

Answer 38

Claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues

Question 39

Discharge planning

Answer 39

Involves arranging appropriate health care services for the discharged patient

Question 40

Downcoding

Answer 40

Assigning lower level codes than documented in the record

Question 41

Electronic data interchange

Answer 41

Computer to computer exchange of data between provider and payer

Question 42

Electronic flat file format

Answer 42

Series of fixed length records submitted to payers to bill for health care services

Question 43

Electronic funds transfer

Answer 43

System by which payers deposit funds to the provider’s account electronically

Question 44

Electronic funds transfer act

Answer 44

Established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems

Question 45

Electronic healthcare network accreditation commission

Answer 45

Organization that accredits clearinghouses

Question 46

Electronic remittance advice

Answer 46

Remittance advice that is submitted to the provider electronically and contains the same information as a paper based remittance advice; providers receive ERA more quickly

Question 47

Encounter form

Answer 47

Financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during current encounter

Question 48

Equal credit opportunity act

Answer 48

Prohibits discrimination on the basis of race, color, religion, nationality, sex, marital status, age, receipt of public assistance, or good faith exercise of any rights under the consumer credit protection act

Question 49

Fair credit and charge card disclosure act

Answer 49

Amended the truth in lending act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open end credit and charge accounts and other circumstances; this law applies to providers that accept credit cards