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2015 NHA CBCS Vocab
vocabulary study stack for NHA CBCS
| Term | Definition |
|---|---|
| Abstracting | The extraction of specific data from a medical record, often for use in a external database |
| Abuse | Practice that directly or indirectly result in unnecessary costs to the Medicare program |
| Account number | Number that identifies specific episode of care, date of service, or patient |
| Account Receivable Department | Department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment |
| Activity/status date | Indicates the most recent activity of an item |
| Actual charge | The amount the provider charges for the health care services |
| Administration Simplification Compliance Act (ASCA) | Prohibits any payment by Medicare for services or medically necessary supplies that are not submitted electronically |
| Administrative Services Only (ASO) Contract | Contract between employers |
| Advance beneficiary notice of noncoverage | From provided if a provider believes that a service may be declined because Medicare might consider it unnecessary |
| Aging report | Measures the outstanding balances in each account |
| Allowable charge | The amount an insurer will accept as full payment, minus applicable cost sharing |
| APC grouper | Helps coders determine the appropriate ambulatory payment classification (APC) for a outpatient encounter |
| Assignment of benefits | Contract in which the provider directly bills the payer and accepts the allowable charge |
| Auditing | Review of claims for accuracy and completeness |
| Authorization | Permission granted by the patient or the patients representatives to release |
| Balance billing | Billing patients for charges in excess of the Medicare fee schedule |
| Batch | A group of submitted claims |
| Blue Cross and Blue Shield plan | The first prepaid plan in the U.S. that offers health insurance to individuals, small businesses, seniors, and large employer groups |
| Business associate (BA) | Individuals, groups, or organizations who are not members of a covered entity's workforce that perform functions or activities on behalf of or for a covered entity |
| Capitation | The fixed amount a provider receives |
| Case management | A review of clinical services being performed |
| Category I CPT code | Code that covers physicians services and hospital outpatient coding |
| Category II CPT code | Code designed to serve as supplement tracking codes that can be used for performance measurement |
| Category III CPT code | Code used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book |
| Charge amount | The amount the facility charges for the procedure or service |
| Charge description master (CDM) | Information about health care services that patients have received and financial transactions that have taken place |
| Charge or service code | Internally assigned number unique to each facility |
| Claim | A complete record of services provided by a health care professional, along with appropriate insurance information, submitted for reimbursement to a third party payer |
| Claim adjustment reason code | Provides financial information about claims decisions |
| Claim scrubber | Software that reviews a claim prior to submission for correct and complete data, such as accurate gender in alignment with diagnosis/procedure or medical necessity |
| Clean claim | Claim that is accurate and complete |
| Clearinghouse | Agency that converts claims into a standard electronic format, looks for errors, and formats them according to HIPAA and insurance standards |
| Clinical documentation | The record of clinical observations and care a patient receives at a health care facility |
| Commercial insurance | Private and employer based self insurance |
| Computer assisted coding | Software that scans the entire patients electronic record and codes the encounter based on the documentation in the record |
| Conditional payment | Medicare payment that is recovered after primary insurance pays |
| Consent | A patient's permission evidenced by signature |
| Contractual obligation | Used when a contractual agreement resulted in an adjustment |
| Coordination of benefits rules | Determines which insurance plan is primary and which is secondary |
| Correction and renewal | Used for correcting a prior claim |
| Cost sharing | The balance the policyholder must pay to the provider |
| Crossover claim | Claim submitted by people covered by a primary and secondary insurance plan |
| De-identified information | information that does not identify and individual because unique and personal characteristics have been removed |
| Demographic information | Date of birth, sex, marital status, address, telephone number, relationship to subscriber, and circumstances of condition |
| Description of service | An evaluation and management visit, observation, emergency room visit |
| Diagnosis code | international classification of diseases (ICD-9-CM volumes 1 and 2) |
| Dirty claim | Claim that is inaccurate, incomplete, or contains other errors |
| E Codes | Codes used to classify environment events, circumstances, and conditions such as the cause of injury or other adverse events |
| Electronic data interchange (EDI) | The transfer of electronic information in a standard format |
| Employer based self insurance | insurance that is tied to an individuals place of employment |
| Encoder | Software that suggests codes based on documentation or other input |
| Encounter | A direct, professional meeting between a patient and a health care professional who is licensed to provide medical services |
| Encounter form | Form that includes information about past history, current history, inpatient record, discharge information, and insurance information |
| Explanation of benefits (EOB) | Describes the services rendered, payment covered, and benefit limits and denials |
| Fair debt collection practices act (FDCPA) | Debt collectors cannot use unfair or abusive practices to collect payments |
| False claims act | Protects the government from being overcharged for services provided or sold, or substandard goods or services |
| Final rule | Strengthens the HIPPA ruling around privacy, security, breach notification, and penalties |
| Formulary | A list of prescription drugs covered by an insurance plan |
| Fraud | Making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist |
| Gatekeeper | Provider who determines the appropriateness of the health care service, level of health care professional called for, and setting for care |
| General ledger key | Two-or three digit number that makes sure that a line item is assigned to the general ledger in the hospitals accounting system |
| Group code | Code that identifies the party financially responsible for a specific service or the general category of payment adjustment |
| Group or plan number | Unique code used to identify a set of benefits of one group of type of plan |
| Group practice model | HMO that contracts with an outside medical group for services |
| Health insurance portability and accountability act (HIPAA) of 1996 | Legislation that includes title II, the first parameters designed to protect the privacy and security of patient information |
| Health maintenance organization (HMO) | Plan that allows patients to only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency |
| Health record number | Number the provider uses to identify an individual patients record |
| ICD-10-CM | Coding and classification system that captures diseases and health related conditions |
| ICD-10-PCS | Coding and classification system developed for use in the U.S. only |
| Implied consent | A patient presents for treatment, such as extending an arm to allow a venipuncture to be performed |
| Independent practice association model | HMO that contracts with the IPA, which in turn contracts with individual health providers |
| Individually identifiable | Documents that identify the person or provider enough information so that the person could be identified |
| Informed consent | Providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions |
| Managed care organization | Organization developed to manage the quality of health care and control costs |
| Medicaid | A government based health insurance potion that pays for medical assistance for individuals who have low income |
| Medical necessity | The documented need for a particular medical intervention |
| Medicare administrative contractor (MAC) | Processes Medicare Parts A and B claims from hospitals, physicians, and other providers |
| Medicare advantage (MA) | Combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness or drug coverage |
| Medicare | Federally funded health insurance provided to people age 65 or older, people younger then 65 who have certain disabilities, and people of all ages with end stage kidney disease |
| Medicare Part A | Provides hospitalization insurance to eligible individuals |
| Medicare Part B | Voluntary supplement medical insurance to help pay for physicians and other medical professionals services, medical services, and medical surgical supplies not covered by Medicare Part A |
| Medicare Part D | A plan run by private insurance companies and other venders approved by Medicare |
| Medicare specialty plan | Plan that provides focused, specialized health care for specific groups of people |
| Medicare summary notice (MSN) | Document that outlines the amounts billed by the provider and what the patient must pay the provider |
| Medigap | A private health insurance that pays for most of the chargers not covered by Parts A and B |
| Modifier | Additional information about types of services, and part of valid CPT or HCPS codes |
| Morbidity | The number of cases of disease in a specific population |
| Mortality | The incidence of death in a specific population |
| MS-DRG grouper | Software that helps coders assign the appropriate Medicare severity diagnosis-related group bases on the level of services provided |
| National provider identifier | Unique 10 digit code for providers required by HIPAA |
| Network model | HMO that contracts with 2 or more independent practices |
| Notice of exclusions from Medicare benefits | Notifications by the physicians to a patient that a service will not be paid |
| Ordering provider | A physician or other licensed health care professional who prescribes services for a patient |
| Other adjustment | Used when no other code applies to the adjustment |
| out of network | Not contracted with the health plan |
| out of pocket maximum | A predetermined amount after which the insurance company will pay 100% of the cost of medical services |
| Patient responsibility | The amount the patient owes |
| Preauthorization | The health plan is notified that a hospital stay or significant procedure is coming up and giving the plan the opportunity to determine if its medically necessary |
| Preferred provider | Tier 2 provider |
| Primary insurance | insurance that pays first, up to the limits of its coverage |
| Privacy Rule | A HIPAA rule that established protections for the privacy of individuals health information |
| Private insurance | Health care subsidized through premiums paid directly to the company |
| Protected health information | Individually identifiable health information |
| Provider level adjustment reason code | Codes that are not related to a specific claim |
| Referral | Written recommendation to a specialist |
| Referring provider | The physician or other licensed health care professional who requests a service for a patient |
| Reimbursement | Payment for services rendered from a third party payer |
| Remittance advice | The report sent from the third party payer to the provider that reflects any changes made to the original billing |
| Remittance advice remark code | Code that explains the reason for a payment adjustment |
| Revenue code | Code that identifies specific accommodation, ancillary service, or billing calculation related to service on a bill |
| Staff model | HMO that provides hospitalization and physician services through its own staff |
| Stark law | Physicians are not allowed to refer patients to a practitioner with whom they have a financial relationship |
| State Children's Health Insurance Program (SCHIP) | A program jointly funded by the federal government and the states |
| Subscriber number | Unique code used to identify a subscribers policy |
| Subscriber | Purchaser of the insurance or the member of group for which an employer or association as purchased insurance |
| Supervising provider | The physician monitoring a patients care |
| Third-party payer | Organization other than a patient who pays for services, such as insurance companies, Medicare and Medicaid |
| Tier 1 | Provides and facilities in a PPO's network |
| Tier 2 | Provides and facilities within a broader, contracted network of the insurance company |
| Tier3 | Providers and facilities out of network |
| Tier 4 | Providers and facilities not on the formulary |
| Timely filing requirement | Within 1 calendar year of a claims date of service |
| UB-04 Code | 3 digit code that describes a classification of a product or service provided to the patient |
| Unbundling | Using multiple codes that describes different components of a treatment instead of using a single code that describes all steps of the procedure |
| Upcoding | Assigning a diagnosis or procedure code at a higher level then the documentation supports |
| Utilization review | A process used to determine the medical necessity of a particular or service |
| V codes | Codes used to classify visits when circumstances other then disease or injury are the reason for the appointment |
| Write off | The difference between the providers actual charge and the allowable charge |
Created by:
tina.reynolds
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