Revenue Cycle Flashcards
Accept assignment
Provider accepts as payment in full whatever is paid in the claim by the payer (exception: copay and Coinsurance)
Accounts receivable
The amount owed to a business for services or goods provided
Accounts receivable aging report
Shows the status by date of outstanding claims from each payer, as well as payments due from patients
Accounts receivable management
Assists providers in the collection of appropriate reimbursement for services rendered; including functions such as insurance verification/ eligibility and pre authorization of services
Allowed charge
The maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
ANSI asc x12n
An electronic format that uses a variable- length file format to process transactions for institutional, professional, dental, and drug claims
Appeal
Document as a letter, signed by the provider, explaining why the claim should be reconsidered for payment
Assignment of benefits
The provider receives a reimbursement directly from the payer
Bad debt
Accounts receivable that cannot be collected by the provider or a collection agency
Beneficiary
The person eligible to receive health care benefits
Birthday rule
Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan
Case management
Development of patient care plans to coordinate and provide care for complicated cases in a cost effective manner
Charge master
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)
Charge master maintenance
Process of updating and revising key elements of the charge master to ensure accurate reimbursement
Claims adjudication
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
Claims adjustment reason code
Reason for denied claim as reported on the remittance advice or explanation of benefits
Claims attachment
Medical report substantiating a medical condition
Claims denial
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
Claims processing
Sorting claims upon submission to collect and verify information about the patient and provider
Claims rejection
Unpaid claims returned by third party payers because it fails to meet certain data requirements, such as missing data
Claims submission
The transmission of claims data to payers from clearinghouses for processing
Clean claim
A correctly completed standardized claim
Clearinghouse
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
Closed claim
Claims for which all processing, including appeals, has been completed
Coinsurance
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 necessity of tests and procedures ordered during a in patient hospitalization
Consumer credit protection act of 1968
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
Coordination of benefits
Provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies
Covered entity
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
Data analytics
Tools and systems that are used to analyze clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments
Data mining
Extracting and analyzing data to identify patterns, whether predictable or unpredictable
Data warehouse
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
Day sheet
Chronological summary of all transactions posted to individual patient ledgers/ accounts on a specific day
Deductible
Amount for which the patient is financially responsible before an insurance policy provides coverage
Delinquent claim
Claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due
Delinquent claim cycle
Advances through various aging periods; with practices typically focusing internal recovery efforts on older delinquent accounts
Denied claim
Claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues
Discharge planning
Involves arranging appropriate health care services for the discharged patient
Downcoding
Assigning lower level codes than documented in the record
Electronic data interchange
Computer to computer exchange of data between provider and payer
Electronic flat file format
Series of fixed length records submitted to payers to bill for health care services
Electronic funds transfer
System by which payers deposit funds to the provider’s account electronically
Electronic funds transfer act
Established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems
Electronic healthcare network accreditation commission
Organization that accredits clearinghouses
Electronic remittance advice
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
Encounter form
Financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during current encounter
Equal credit opportunity act
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
Fair credit and charge card disclosure act
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
