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Vocabulary for Claim Processing Unit_Grade 11

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