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Insurance Ch14-15

Medical necessity denial Apair refusal to pay for report procedure due to medical
Overpayments Improper or overpayment billing error
MRN Letter from Medicare to apatite regarding as appeal
Insurance aging report Analysis of how long the payer has held submit claims
Pending Claim status waiting on information
Development Payer attention together clinic (for the claim before payment)
EFT Banking service
Concurrent care Medical situation where a patient receive care from 2 or more physician in the same day
Determination Payer decision on a payment
Guarantor billing Sending one payment to the guarantor
Skip trace process of locating a patient with a outstanding balance
Patient aging report Overdue billing
Retention schedule Summarize the practice of keeping policy
Patient refunds When the practice over charge a patient
Uncollectible account A balance the practice hasn't collected
Payment plan Program set up for the patient schedule to pay
Cycle billing Assign patient to a specific time of the month the patient with statement
Credit report Process where the unpaid medical bills can be reviewed
The payer's processing of claim is called? Adjudication
A payer's determination means it is going to what? Pay deny or pay half
Determination means what? Payer decision
A payer's automated claim edit may result in claim denial because? Lack of eligibility, medical necessity
A claim that is removed from a payer's automated processing system is sent for? Manual review
When a claim is pulled by a payer for a manual review, the provider may be asked to submit what? Documentation
What is a CONCURRENT CARE? When a patient sees 2 or more physicians
If there is a problem during the automated review during the adjustment process what would happen? The claim is pulled for development
The HIPAA 835 is sent to do what? Is sent to the payer to explain a claim payment
HIPAA 276 is used by the medical office for what? The status for the claim
A payer's initial claim review may reject a claim due to? Invalid policy number
HIPAA 276 is used by the medical offices for what Sent by the payer for a submit claim
A list of claims transmitted and how long they have been in process with the payer is shown where? Aging report
On the aging report, what range would show the current invoice? 0-30 days passed due after 30 days
What kind of code appears on a payer's electronic reports on the progress of transmitted claims in the adjudication process? Claim status Category code
If a provider has accepted assignment, who will the payer send the RA/EOB to? Provider
If a provider has not accepted assignment, who will the payer send the RA/EOB to? Patient
What codes might payers use to explain a determination? All the above by CMS
The process of verifying that the totals on the RA/EOB are mathematically correct? Reconciliation
The advantages of EFT for practice are? Funds are available
The person filing an appeal is known as? Climate or appellant
The first step in the Medicare appeals process is called? Redetermination
Improper or excessive payments is known as? Over payment
If a patient has additional insurance, after the primary payer's RA/EOB has posted what would be the next step? Billed the Secondary insurance
Effective patient billing begins with? Sound financial policy
A summary of financial transactions that occur each day is called? Day Sheet
Printed bill that shows the amount a patient owes is called? Statement
What is used by the insurance specialist to update the patient billing program with the payer's payment and the amount due from the patient? RA/EOB
What type of billing spreads out the workload of mailing statements? Cycle billing
Patient are grouped under the insurance policyholder in what type of billing? Guarantor billing
Who creates and implement the practice's collection policy? Billing collection manger
The job of accurately recording the funds that come in and out of the office is done by who? Book keeper
The term collection refers to what? Payment problems
What term mean stealing of funds? Embezzlement
A patient's first notice that their bill is past due is usually? Collect letter
The law that regulates the calling hours and collection methods is? Telephone consumer act
A legal declaration of the inability to pay debts is known as? Bankruptcy
An account that is determined to be uncollectible? Bad debt
When a patient needs to be refunded because there were overcharged for services? Patient refund
A patient's retention schedule protects? The provider and patient
Created by: kayymoore