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Claims Processing

Sophomore Unit Claims Processing

TermDefinition
Medicare federally funded health insurance provided to people age 65 or older, people younger than 65 who have certain disabilities, and people of all ages with end stage kidney disease. Funded and administered at the national level
Medicaid A government based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Funded at the state and national level. Administered at the state level.
Medicare timely filing requirement claims are required to be submitted within 1 year of date of service to Medicare
EDI (electronic data interchange) the transfer of electronic information in a standard format
COB (coordination of benefits) determines which insurance plan is primary and which is secondary
conditional payment Medicare payment that is recovered after primary insurance pays.
crossover claims claim submitted by people covered by a primary and secondary insurance plan
clean claim claim that is accurate and complete. Contains all teh information needed for processing, which is done in a timely manner.
dirty claim claim that is inaccurate, or contains other errors
assignment of benefits contract in which the provider directly bills the payer and accepts the allowable charge
allowable charge the amount an insurer will accept as full payment, minus applicable cost sharing
MAC (Medicare Administrative Contractor) Processes Medicare Parts A and B claims from hospitals, physicians, and other providers.
RA (remittance advice) report sent from the third-party payer to the provider that reflects any changes made to the original billing; payments, denials, pend status, etc
EOB (explanation of benefits) describes the services rendered, payment covered, and benefit limits and denials
NPI (National Provider Identifier) unique 10 digit code for providers required by HIPAA
HMO (health maintenance organization) plan that allows patients to only go to physicians other health are professionals, or hospitals on a list of approved providers, except in an emergency
procedure code code that represents the procedure or service preformed
modifier additional information about types of services, and part of valid CPT or HCPCS codes
claim adjudication the insurance carrier process reviewing claims to determine payment or denial after comparing them to the benefit or coverage requirements
patient statement printed bill that displays the details such as the amount that each patient has to pay, service dates, charges, and transaction descriptions
private insurance Private health insurance refers to health insurance plans marketed by the private health insurance industry, as opposed to government-run insurance programs.
Tricare Health care program of the United States Department of Defense Military Health System, covering military members, dependents, and retirees
Workers Compensation Employer purchased plan designed to cover employee injuries and / or illnesses that are incurred on the job.
Created by: tina.reynolds