Health Ins and Claims-Chapter 4
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| provider accepts as payment in full whatever is paid on the claim by the payer (except for any copaymetn and/or coinsurance amounts) | accept assignment
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| the amount owed to a business for services or goods provided | accounts receivable
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| the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy | allowed charges
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| documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. | appeal
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| the provider receives reimbursement directly from the payer | assignment of benefits
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| 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 ser | claims adjudication
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| sorting claims upon submission to collect and verify information about the patient and provider | claims processing
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| the transmission of claims data (electromically or manually) to payers or clearinghouses for processing | claims submission
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| a correctly completed standarized claim | clean claim
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| performs centralized claims processing for providers and health plans. Facilitates the processing of non-standard data elements into standard data elements | clearinghouse
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| also called coinsruance paymetn; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid | coinsurance
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| abstract of all recent claims filed on each patient | common data file
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| provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other polcies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim | coordination of benefits (COB)
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| also called manual daily accounts receivable journal; chronologically summary of all transactions posted to individual patient ledgers/accounts on a specific day | day sheet
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| amount for which the patient is financially responsible before an insurance policy provides coverage | deductible
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| remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly. | electronic remittance advice (ERA)
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| financial record source documetn used by providers and other personnel to record treated diagnosise and services rendered to the patient during the current encounter | encounter form
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| person responsible for paying health care fees. | guarantor
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| contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed | participating provider (PAR)
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| also called patient account record; a computerized permanent record of all financial transactions between the patient and the practice | patient ledger
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| any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage | preexisting condition
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| term used for an encounter form in the physician's office | superbill
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| submitting multiple CPT codes when one code should be submitted | unbundling
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