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Health Ins. Chapter 4

Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and /or coinsurance amounts accept assignments
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 (electronically or manually) to payers or clearinghouses for processing claims submission
a correctly completed standardized 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 coinsurance payment; 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 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 document used by providers and other personnel to record treated diagnoses 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 enrollees 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
_________ means that the patient and/or insured has authorized the payer to reimburse the provider directly. assignment of benefits
Providers who do not accept assignment of Medicare benefits do not receive information included on the_____, which is sent to the patient. Medicare Summary Notice
The transmission of claims data to payers or clearinghouses is called claims: submission
Which facilitates processing of nonstandard claims data elements into standard data elements? clearinghouse
A series of fixed-length records submitted to payers to bill for health care services is an electronic: flat file format
What is considered a covered entity? private sector payers that process electronic claims
An electronic claim that is rejected because of an error or omission is considered an: open claim
Which would be used to transmit electronic claims? magnetic tape
Which supporting documentation is associated with submission of an insurance claim? claims attachment
Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies? coordination of benefits
The sorting of claims by clearinghouses and payers is called claims: processing
Which of the following steps would occur first? Health Insurance specialist completes electronic claim
Comparing the claim to payer edits andthe patient's health plan benefits is part of claims: adjudication
Which describes any procedures or service reported on a claim that is not included on the payer's master benefit list? noncovered benefit
Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider? common data file
Which is the fixed amont patients pay each time they receive health care services? copayment
Which of the following steps would occur first? clearinghouse transmits claims data to payers
Which must accept whatever a payer reimburses for procedures or services performed? participating provider
Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household? the parent whose birth month and day occurs earlier in the calender year is the primary policyholder
Which is the financial record source document usually generated by a hospital? chargemaster
Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions? truth in lending act
Which protects information collected by consumer reported agencies? fair credit reporting act
Which is the best way to prevent deliquent claims? verify health identification information on all patients
Which is a characteristic of deliquent commercial claims awaiting payer reimbursement? the deliquent claims are resolved directly with the payer
Which is an example of suporting documentation? operative report
Which term does the CPT manual use to refer to supporting documentation? special report
Which claim status is assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration? clean claim
The intent of mandating HIPAA's national standards for electronic transactions was to: improve the efficiency and effectiveness of the health care system
Electronic claims are more accurate because they are: checked for accuracy by billing software programs or a health care clearinghouse
Patients can be billed for: noncovered procedures
Medicare calls the remittance advice a: provider remittance notice
The person in whose name the insurance policy is issued is the: policyholder
The life cycle of an insurance claim is initiated when the: health insurance specialist completes the CMS-1500 claim
What is considered a financial source document: superbill or encounter form
Which federal law protects consumers against harassing or threatening phone calls from collectors? fair debt collection practices act
A clearinghouse that coordinates with other entities to provide additional services during the processing of claims is a: value-added network
Created by: kduvall20