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Health Ins and Claims-Chapter 4

provider accepts as payment in full whatever is paid on the claim by the payer (except for any copaymetn and/or coinsurance amounts) accept assignment
the amount owed to a business for services or goods provided accounts receivable
the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy allowed charges
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
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 performed or ser claims adjudication
sorting claims upon submission to collect and verify information about the patient and provider claims processing
the transmission of claims data (electromically or manually) to payers or clearinghouses for processing claims submission
a correctly completed standarized claim clean claim
performs centralized claims processing for providers and health plans. Facilitates the processing of non-standard data elements into standard data elements clearinghouse
also called coinsruance paymetn; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid coinsurance
abstract of all recent claims filed on each patient common data file
provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other polcies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim coordination of benefits (COB)
also called manual daily accounts receivable journal; chronologically summary of all transactions posted to individual patient ledgers/accounts on a specific day day sheet
amount for which the patient is financially responsible before an insurance policy provides coverage deductible
remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly. electronic remittance advice (ERA)
financial record source documetn used by providers and other personnel to record treated diagnosise and services rendered to the patient during the current encounter encounter form
person responsible for paying health care fees. guarantor
contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed participating provider (PAR)
also called 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 treated within a specified period of time immediately preceding the enrollee's effective date of coverage preexisting condition
term used for an encounter form in the physician's office superbill
submitting multiple CPT codes when one code should be submitted unbundling
Created by: Kcompleta
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