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ClaimProcessingUnit
Vocabulary for Claim Processing Unit_Grade 11
| Term | Definition |
|---|---|
| clearinghouse | edits and routes electronic claims to the insurance carrier for payment |
| audit | review or formal examination of a provider's accounting or a patient's medical records |
| adjudication | the process health plans follow to examine claims and determine payment |
| policyholders | owners of a health insurance policy |
| practice management system | software that deals with the administrative and financial operations of a medical practice, including patient registration, scheduling, claims submission, and billing |
| carrier block | data entry area located in the upper right corner of the CMS-1500 that allows for a four-line address for the payer |
| insurance adjustments | any remaining portion once an insurance carrier meets it's financial responsibility and the patient responsibility is determined; portion must be written off of the account according to the provider's contract |
| covered expenses | health insurance reimbursement for medically-related expenses |
| allowed amount | maximum dollar amount the third party will reimburse a provider for a specific service |
| Adjustment | remaining portion after the insurance carrier has met its financial responsibility and patient responsibility |
| explanation of payment (EOP) | itemized statement provided to providers after a claim has been processed |
| remittance advice (RA) | itemized (listing each charge one by one) statement provided to providers after a claim has been adjudicated |
| explanation of benefits (EOB) | itemized statement provided to policy members after a claim has been processed |
| covered entities | health plans, health care clearinghouses, or health care providers that conduct health information in electronic form in connection with a transaction covered by HIPAA |
| electronic billing | process of submitting medical claims electronically to an insurance carrier for reimbursement of services rendered by a health care provider |
| electronic data interchange (EDI) | secure system-to-system interchange of data in a standardized format |
| denied claim status | claim status indicating a claim has been processed, but contained incorrect or incomplete information; a claim may also be denied for medical necessity |
| eligibility verification | confirmation that the patient is entitled to benefits by verifying the name of the insurance carrier, the effective date of active coverage, policy information, group number, co-payments, and deductible; typically performed before services are rendered |
| employer identification number (EIN) | unique identifier issued by the Internal Revenue Service (IRS) for employers as required by HIPAA Electronic Health Care Transactions and Code Sets |
| ANSI ASC X12 837 | HIPAA mandated electronic transaction standard for claims, usually called the 837 claim or the HIPAA |
| incomplete claim status | claim status indicating a claim is missing required information |
| invalid claim status | claim status indicating a claim contains complete information, but the information may be incorrect and cannot be processed by the carrier |
| National provider identifier (NPI) | Unique identifier issued by CMS as the standard of identification for health care providers |
| National Uniform Claim Committee (NUCC) | led by the American Medical Association (AMA) and determines the content of CMS-1500 |
| optical scanning | process used to convert printed or hand written characters into text that can be viewed by an optical character reader (OCR); all CMS-1500 claims must conform to OCR guidelines |
| patient encounter form | itemized list of provider charges generated by a hospital or by a provider's office for services rendered; AKA superbill |
| pending claim status | claim status indicating the payer is waiting for information from the submitter during adjudication |
| rejected claim status | claim status indicating the claim has not been paid due to incorrect information |
| turnaround time | the time calculated from the date of service until the date of payment for services rendered |
| UB-04 | standard claim form or uniform bill (UB) for institutional health care providers; used for inpatient hospital and outpatient hospital facility charges, home health, skilled nursing facility charges, and ambulatory surgery centers |
| chargemaster | hospital version of encounter form |
| patient ledger | permanent record of all financial transactions between the patient and the practice. This can be electronic or paper |
| day sheet (daily accounts receivable journal) | chronologic summary of all transactions posted to individual patient ledgers/ accounts on a specific day |
| value-added network (VAN) | clearing house that involves value-added vendors such as banks in the processing of claims |
| claims attachment | set of supporting documentation or information associated with a healthcare claim or patient encounter. located in remarks or notes fields of electronic claims or paper forms. |
Created by:
tina.reynolds
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