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Completa
Health Ins and Claims-Chapter 4
| Question | Answer |
|---|---|
| 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 |
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Kcompleta
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