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Chapter 1

Medical Billing Key Terms

accounting cycle the flow of financial transactions in a business
accounts receivable monies that are flowing into a business
adjudication series of steps that determine whether a claim should be paid
billing cycle regular schedule of sending statements to patients
capitation advance payment to a provider that covers each plan member's health care services for a certain period of time
coding a way of translating a description of a condition into a shorter, standardized code
coinsurance part of charges that an insured person must pay for health care services after payment of the deductible amount
consumer-driven health plan (CDHP) a type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit
copayment a small fixed fee paid by the patient at the time of an office visit.
diagnosis physician's opinion of the nature of the patient's illness or injury
diagnosis code a standardized value that represents a patient's illness, signs, and symptoms.
encounter form a list of the procedures and charges for a patient's visit.
explanation of benefits (EOB) paper document from a payer that shows how the amount of a benefit was determined
fee-for-service health plan that repays the policyholder for covered medical expenses
Health Maintenance Organization (HMO) a managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan
health plan a plan, program, or organization that provides health benefits
managed care a type of insurance in which the carrier is responsible for both the financing and the delivery of health care
medical coder a person who analyzes and codes patient diagnoses, procedures, and symptoms
medical necessity treatment provided by a physician to a patient for the purpose fo preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice.
patient information form form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim
payer private or government organization that insures or pays for health care on the behalf of the beneficiaries
policyholder a person who buys an insurance plan; the insured
practice management program (PMP) a software program that automates many of the administrative and financial tasks required to run a medical practice
Preferred Provider Organization (PPO) managed care network of health care providers who agree to perform services for plan members at discounted fees
premium the periodic amount of money the insured pays to a health plan for insurance coverage
procedure medical treatment provided by a physician or other health care provider
procedure code a code that identifies a medical service
remittance advice (RA) an explanation of benefits transmitted electronically by a payer to a provider
statement a list of all services performed for a patient, along with the charges for each service.