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Ch. 4 Reimbursement

Processing an Insurance Claim

QuestionAnswer
Provider accepts payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts). Accept Assignment
The amount owed to a business for services or good provided. Accounts Receivable
Shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. Accounts Receivable Aging Report
Assists providers in the collection of appropriate reimbursement for services rendered; include functions such as insurance verification/eligibility and preauthorization of services. Accounts Receivable Management
The maximum amount the payer will reimburse for each procedure or service, according to the patient's policy. Allowed Charge
An electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims. ANSI ASC X12
Documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. Appeal
the provider receives reimbursement directly from the payer. Assignment of Benefits
Accounts receivable that cannot be collected by the provider or a collection agency. Bad Debt
The person eligible to receive healthcare benefits. Beneficiary
Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. Birthday Rule
Term hospitals use to describe a patient encounter form. Chargemaster
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 or services are Claims Adjudication
Medical report substantiating a medical condition. Claims Attachment
Sorting claims upon submission to collect and verify information about the patient and provider. Claims Processing.
The transmission of claims data (electronically or manually) to payers or clearing houses for processing. Claims Submission
A correctly completed standardized claim Clean Claim
Performs centralized claims processing for providers and health plans. Clearinghouse
Claims for which all processing, including appeals, has been completed. Closed Claim
Abstract of all recent claims filed on each patient. Common Data File
Was considered landmark legislation because it launched 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 better Consumer Credit Protection Act of 1968
Provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim. Coordination of Benefits (COB)
private sector heatlh plans, managed care organizations, ERISA-covered health benefit plans, and government health plans; all healthcare clearinghouses; and all healthcare providers that submit or receive transactions electronically. Covered Entity
also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day. Day Sheet
One that has not been paid within a certain time frame Delinquent Account
Claim usually more than 120 days past due; some practices establish timr frames that are less than or more than 120 days past due. Delinquent Claim
Advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (120 days or more). Delinquent Claim Cycle
Assigning lower-level codes than documented in the record. Downcoding
Sending data in a standardized machine-readable format to an insurance company via disk, telephone, or cable. Electronic Claims Processing
Computer-to-computer exchange of data between provider and payer. Electronic Datta Interchange (EDI)
Series of fixed-length records (25 spaces for patient's name) submitted to payers to bill for healthcare services. Electronic Flat File Format
System by which payers deposit funds to the provider's account electronically. Electronic Funds Transfer (EFT)
Established the rights, libailities, and responsibilities of participants in electronic funds transfer systems. Electronic Funds Transfer Act
Organization that accredits clearinghouses. Electronic Healthcare Network Accreditation Commisson (EHNAC)
Series of fixed-length records (25 spaces for patient's name) submitted to payers to bill for healthcare services. Electronic Media Claim
Financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. Encounter Form
Prohibits discrimination on the basis of race, color, religion, national origin,sex, marital status, age, receipt of public assistance, or good faith exercise of any right under the consumer Credit Protection Act. Equal Credit Opportunity Act
Amended the Truth in Lending Act, requiring credit and charge cared issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-end credit and charge accounts and under other circumstances Fair Credit and Charge Card Disclosure Act
Federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory good and services; Fair Credit Billing Act
Protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations Fair Credit Reporting Act
Specifies what a collection source may and may not do when pursuing payment of past due accounts. Fair Debt Collection Practices Act (FDCPA)
Person responsible for paying healthcare fees. Guarantor
Legal action to recover a debt; usually a last resort for medical practice. Litigation
also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day. Manual Daily Accounts Receivable Journal
Any procedure or service reported on a claim that is not included on the payer's master benefit list, resulting in denial of the claim; also called noncovered procedure or uncovered benefit. Noncovered Benefit
Does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses. Nonparticipating Provider (nonPAR)
Submitted to the payer, but processing is not complete. Open Claim
Established by health insurance companies for a health insurance plan; usually has limits of $1,000 or $2,000; when the patient has reached the limit of an out-of-pocket payment for the year, appropriate patient reimbursement to the provider is determined Out-of-Pocket Payment
Contract out. Outsource
Contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. Participating Provider (PAR)
One that has not been paid within a certain time frame (120 days); also called delinquent account. Past-due Account
also called patient ledger; a computerized permanent record of all financial transactions between the patient and the practice. Patient Account Record
also called a patient account record; a computerized permanent record of all financial transactions between the patient and the practice. Patient Ledger
Any medical condition that was diagnosed and/or treatment within a specified period of time immediately preceding the enrollee's effective date of coverage. Preexisting Condition
Associated with how an insurance plan is billed - the insurance plan responsible for paying healthcare insurance claims first is considered primary. Primary Insurance
Remittance advice submitted by Medicare to providers that includes payment information about a claim. Provider Remittance Notice (PRN)
The routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated. Source Document
Term used for an encounter form in the physician's office. Superbill
Pending Suspense
Was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could shop for a better deal. Truth in Lending Act
Check made out to both patient and provider. Two-party Check
Generated for providers who do not accept assignment; organized by year Unassigned Claim
Services that are provided to a patient without proper authorization or that are not covered by a current authorization. Unauthorized Service
Submitting multiple CPT codes when one code should be submitted. Unbundling
Clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers than managing their own systems to send and receive transactions directly from numerous entities. Value-added Network (VAN)
Created by: adale3171