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claim processing_3

TermDefinition
optical scanning a process used to convert printed or handwritten characters into text than can be viewed by an optical character reader (OCR); all CMS 1500 claims must conform to OCR guidelines.
patient encounter form an itemized list of provider charges generated by a hospital or by a physician's office for services rendered; also known as a superbill.
patient information section items 1 through 13 on the CMS 1500 used to identify the patient, the insured, the health plan, and other case-related data, including the assignment of benefits/release of information.
payer of last resort Medicaid, a joint federal and state program that helps with medical costs for some low income persons and persons with disabilities; all other payers must meet their financial responsibility before Medicaid claims can be submitted.
pending claim status claim status indicating the payer is waiting for information from the submitter during adjudication.
physician/supplier information section items 14 to 33 on the CMS 1500 used to identify the health care provider, describe services performed, and give the payer additional information to process the claim.
rejected claim status claim status indicating the claim has not been paid due to incorrect information.
second party the physician
service line information items 21 and 24A,B,D,E,F, and G on the CMS 1500 requiring specific information related to diagnosis and service3s rendered in order to process the claim.
third-party payer private or government organizations that insure or pay for health care on the behalf of the insured.
turnaround time the time calculated from the DOS until the date of payment for services rendered.
UB-04 the standard claim form or uniform bill (UB) for institutional health care providers that is used throughout the US.
Created by: tina.reynolds
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