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INSURANCE

Nationals

QuestionAnswer
Accept Assignment Provider accepts as a payment in full whatever is paid on the claim by the payer(expect for any copayment and or coinsurance amounts
Account Receivable The amount the payer will reimburse for each procedure or service
Allowed charges The maximum amount the payer will reimburse fir each procedure or service according to the patient's policy
Bad Debt Accounts receivable that cannot be collected by the provider or collection agency
Beneficiary The eligible to receive healthcare benefits
Charge Master Term hospitals use to describe a patient encounter form
Claim Adjudication Comparing a claim to payer edits and the patients health plan benefits to verify that the required info is available to process the claim; the claim is not duplicate; payer rules and procedures have been follow
Claims attachment Medical report substantiating a medical condition
Claim Processing Sorting claims upon submission to collect and verify information about the patient
Claim Submission The transmission of claims data (electronically or manually) to payers or clearinghouses for processing
Clean claim A correctly completed standardized claim (e.g., CMS-1500 claim)
Clearinghouse Performs centralized claims processing for providers and health plans.
Closed claim Claims for which all processing, including appeals, has been completed.
Coinsurance Coinsurance payment) the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
Common data file Abstract of all recent claims file don each patient
Consumer Credit Protection Act of 1968 Was considered landmark legislations because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges; compare costs, and shop
coordination of benefits (COB) Provision in group health insurance policies the prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim
Covered entity Private sector health plan (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans
Day sheet Manual daily accounts receivable journal) chronological summary of all transactions posted to individual patient ledger/accounts on a specific day.
Deductible Amount for which the patient is financially before an insurance policy provides coverage.
Delinquent claim Claim usually more than 120 days past due'; some practices establish time frames that is less than or more than 120 days past due.
Down coding Assigning lower-level codes than documented in the record.
Delinquent claim cycle Advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts
Electronic data interchange (EDI) computer to computer exchange of data between provider and payer
Electronic flat file format Series of fixed records (e.g., 25 spaces patient's name) submitted to payers to bill for healthcare services
Electronic Healthcare Network Accreditation Commission (EHNAC) Organization that accredits clearinghouses
Fair Credit Reporting Act Protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations
Fair Debt Collection Practices Act (FDCPA) Specifies what a collection source may and may not do when pursuing payment of past due accounts.
Guarantor Person responsible for paying healthcare fees
Litigation Legal action to recover a debt; usually a last resort for a medical practice.
Manual daily accounts receivable journal Also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.
Noncovered benefit Any procedure or service reported on a claim that is not included on the payer's master benefit list, resulting in denial of the claim
Nonparticipating provider (nonPARs) Does not contract with the insurance plan' patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses.
Past-due account Delinquent account one that has not been paid within a certain time frame (e.g., 120 days)
Patient ledger (Patient account record) a computerized permanent record of all financial transactions between the patient and the practice.
Provider Remittance Notice (PRN) Remittance advice submitted by Medicare to providers that includes payment information about a claim
Source document The routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated
Superbill Term used for an encounter form in the physician's office
Suspense Pending
Truth in Lending Act Consumer Credit Protection Act of 1968)was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money
Unassigned claim Generated for providers who do not accept assignment; organized by year.
Unbundling Submitting multiple CPT codes when one code should be submitted.
Unauthorized service Services that are provided to a patient without proper authorization or that are not covered by a current authorization
Value-added network (VAN) Clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers
Electronic remittance advice (ERA) 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.
Fair Credit Reporting Act Protect information collected by consume reporting agencies such as credit bureaus, medial information companies and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations,
Fair Credit Billing Act Federal law passed in 1975 that helps consumers resolve billing issues with care issuers; protect important credit right, including rights to dispute billing errors
Fair Credit and Charge Care Disclosure Act Amended the Truth i Lending Act, requiring credit and charge care issues to provide certain disclousres in direct mail, telephone, and other cirucumstances; this law applies to providers that accept credit cards.
Encounter form Financial record source document used by provider and other personnel to record treated diagnoses and services rendered to the patient during the current encounter
Block 1 This block indicates what kind of insurance is applicable; for example Medicare or Medicaid
Block 1A Medicare health insurance claim number. This number must be recorded whether Medicare is the primary or secondary payer
Block 2 Patients first name, middle initial, and last name, as shown on the patients Medicare card
Block 3 Patients eight-digit date and sex; the birth date
Block 4 Insureds name
Block 5 Patients mailing address and telephone number
Block 6 The patients relationship to the insured
Block 7 Insured's address and phone number
Block 8 Blank
Block 9 Medigap Enrollee name
Block 9A Medigap Enrollee Policy #
Block 9B Medigap Enrollee Birthdate and Sex
Block 9C Blank if block 9d is filled out,
Block 9D Coordination of Benefits agreement Medigap
Blocks 10A-C Block you'll check yes or no to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services
Block 11 It indicates that a good faith effort has been made to determine whether Medicare is the primary insurance
Block 11A Insured's birth date as well as sex
Block 11B Employers name and any change in insurance status
Block 11C 9 digit payer ID # of the primary insurer.
Block 12 Patient or an authorized person signs to authorize the release of medical information
Block 13 Signature authorizes payment of benefits
Block 14 Date of current illness, injury, or pregnancy; it has to have six or eight digits.
Block 15 Blank but only use it if provider is seeing a patient in a facility
Block 16 This is required if the patient is eligible for disability or worker's compensation benefits
Block 17 Has the name of the ordering or physician’s name.
Block 17B The national provider identifier number
Block 18 Hospital dates entered either in a six or eight digit format
Block 19 Dates entered either in a six or eight digit format for when the patient was last seen and the NPI of the attending physician when a physician providing routine foot care submits a claim.
Block 20 If lab tests were done by an entity other than the one doing the billing, the box should be marked YES
Block 21 The diagnosis codes
Block 22 Empty
Block 23 Prior authorization number
Block 24A Contains the dates of service
Block 24B The places of service codes
Block 24C Medicare providers do not have to fill out this block
Block 24D CPT or HCPCS codes will be used
Block 24E The diagnosis reference code. It also matches the date of service to the procedures performed under the primary diagnosis code
Block 24F Providers billed charges for each service
Block 24G The number of days or units
Block 24 I ID qualifier will go in the shaded portion of this block
Block 24J The rendering provider's NPI goes in the unshaded portion
Block 25 the provider's or suppliers ID number or social security number
Block 26 Patients account number as assigned by the provider or supplier goes in this block
Block 27 Will be checked yes or no if the provider accepts assignment of Medicare benefits
Block 28 Will have total charges for all services
Block 29 The total amount the patient paid for covered services only
Block 30 Blank
Block 31 Signature of the provider or the signature of the authorized representative
Block 32 Name, address, and ZIP code of the facility
Block 32A National provider Identifier
Block 33 The providers or suppliers billing name, address, ZIP code, and telephone number
How many dates of service can blocks include for a same procedure code? 02
How are codes shown for place of service? Two digit codes
What is the code used for a pharmacy? 01
What is 02 used as? Unassigned number
What is the code used for a school? 03
What is the code used for a homeless shelter? 04
What should be done if a claim involves more than one referring, ordering, or supervising physician? A Separate claim must be submitted for each physician Referring provider The physician who requests the service for the patient Ordering provider
A physician or other licensed health care professional who prescribes services for a patient Supervising provider
What are the entities covered under HIPAA? The physician monitoring a patient’s care Individuals, organizations, home health agencies, clinics, nursing homes, residential treatment homes, laboratories, ambulances, group practices, and health maintenance organizations
What is block 24g mostly used for? Multiple visits, units of supplies, anesthesia minutes, oxygen volume
Why is block 11 important? This is the place to indicate that a good faith effort has been made to determine which the primary insurance is and which is secondary
Patients demographic for the Claims Form? 2,3,5,7
Left Blank? 8, 9b, 11d, 17a, 22, 24h, 30
What does a group health plan cover? Workers compensation, black lung, veteran’s benefits
What are the other blocks that can be listed for block 19? Name and date of drugs listed as not otherwise classified, Homebound, Patient refuses to sign benefits, testing for hearing aids
What also should be used in block 23 when an investigation device is used in an FDA approved clinical trial? Investigational device exemption
What’s the other information included in block 23? National provider identifier of a home health agency or hospice, 10 digit clinical laboratory improvement act certification number for laboratory services billed by any entity performing CLIA covered procedures
What needs to be done if more than one condition applies to a claim? Separate claims need to be submitted for each condition
What takes place when a work related illness or injury occurs? Group health plan coverage, no fault and or other liability, work related illness or injury These are instances when Medicare is the secondary insurance Working aged, disability, end-stage kidney disease
A claim rejected because of Medicare NCCI edits? Because of improper code combination
A claim is submitted with transposed insurance member ID # and returned because? An Invalid claim contains illogical or incorrect information and returned to the provider unprocessed
DENIED CLAIM Is returned to the provider after it has been processed
Medigap coverage ID offered to Medicare beneficiaries by which of the following? Private 3rd party payer
Medicaid’s supplement coverage Called Medi Medi and it picks up Medicare premium to qualified applicants
Release of Patient Records 1 All request for patient records must be in writing and have signed authorization from the patient, parent, legal guardian
Release of Patient Records 2 ID is required in order to maintain patient confidentiality and privacy
ABUSE Submitting a claim for services that are not medically necessary Violating participating provider Billing no covered service as covered
Fraud Is billing for a service that was never provider
NPI National Provider ID #
Fee schedule Are a list of the provider’s service fee
HCPCS Healthcare Common Procedure Coding System
CPT Current Procedural Terminology is used for procedure coding
ICD International Classification of Disease
Preventing Fraud Performing periodic audit
Medicare part A Inpatients
Medicare part B Outpatients
Medicare part C Both in and out patients
Medicare part D Prescription
Anesthesia section of the CPT manual (qualifying circumstances is? ADD-ON Codes
> Symbol is used for procedure descriptions
Prospective review Ensure the appropriateness and necessity of care provided
Coding Compliance Plan contains Rules, procedures and best practice
Procedures and best practice for correct coding is? Coding Compliance Plan
Health Care clearinghouses is covered by HIPAA regulations included? Providers of health care services and health 3rd party payers who submit
Insurance company denies a service as not medically necessary? Appeal the decision with providers report
Blood cells Are generated in BONE MARROW
Assignment benefits Is a required for Medicare recipients
Retrospective Audit ensure correctness of billing documents
Endo mean inside
Cardium means pertaining to heart
Epi means top
My means Muscle
Peri means around
Uretharatresia mean Obstruction of the Urethra
Urethrism mean Irritability or spasmodic stricture
Urethralgia means Pain
Urethritis mean inflammation
Ambulatory, Surgery centers, Hospice form is? UB-04
HIPAA transaction standards apply to which? Health Care Clearinghouse
algia means pain
emia means blood condition
itis means inflammation
megaly means enlargement
meter means measure
oma means tumor, mass
osis means abnormal condidtion
a, an means not, without, less
pathy means disease condition
rrhagia means bursting forth of blood
rrhea means discharge
sclerosis means hardening
scopy means to view
centesis means surgical puncture
ectomy means removal, resection, excision
gram means records
graphy means process of recording
lysis means separation, breakdown, destruction
pexy means surgical fixation
plasty means surgical repair
rrhaphy means suture
scopy means visual examination
stomy means opening
therapy treatment
tomy means incision, to cut into
ante means before
anti means against
brady means slow
dys means painful, difficult
endo means inside, within
epi means upon
Claim Life Cycle 1 Submission
Claim Life Cycle 2 Processing
Claim Life Cycle 3 Adjudication
Claim Life Cycle 4 Payment
What would cause a claim to be suspended? Service required additional information
Left Upper Quadrant Left lobe of the liver, the stomach, the spleen, part of the pancreas, and part of the small and large intestines
Right Upper Quadrant Right lobe of the liver, the gallbladder, part of the pancreas, part of the small and large intestines
Right Lower Quadrant Part of the small and large intestines, and appendix, and the right ureter
Left Lower Quadrant Part of the small and large intestines, and the left ureter
Medicaid for a patient who had primary and secondary insurance coverage what do you do? Attach the remittance advice from the primary insurance along with the Medicaid
Who Fights waste, fraud, and abuse in Medicare and Medicaid? Office of Inspector General (OIG)
Medigap coverage is offered to which Medicare beneficiary? Private 3rd party payer
Financial record source is? Patient ledge account
Encounter Form Is used for billing
Examination of a sore throat is ? Problem-Focus examination
What Final determination of the issue involving settlement? Adjustication
A transmit to the insurance carrier for reimbursement of inpatient Hospital service is? UB-04
A form that contains charges DOS CPT ICD code fee and copayments is Encounter Form
A unlisted codes can be found where in the CPT manual? Guidelines prior to section each section
Psoriasis Dermatology
Valvuloplasty Open stenotic heart valve
Angioplasty A balloon is threaded into the artery and expanded
Ablation Ablation therapy
+ Add-on codes
A Triangle Means revised code
Encounter Form Is a form that includes info about past and current history, inpatient record, discharge in and out
Pediatric Is for infants, children and teens
Pathology Is disease
Integumentary Is body temp
HCPS LEVEL 2 Appendix's
Appendix A Has a complete list of modifiers and their description
Appendix B Is a summary of the addition, deletion, and revision that has been put into use in the current CPT edition
Appendix C Has clinical example for codes in evaluation and management section of the CPT book
Appendix D Is a list of CPT add-on codes
Appendix E Is a summary of CPT codes that are exempt from modifier 51
Appendix F Is a summary of CPT codes exempt from modifier 63
Appendix G Has a codes that include conscious/moderate sedation
Appendix H Is an alphabetic index of performance measures by clinical conditions or type but was removed from CPT
Appendix I Has genetic testing code modifiers used for reporting with lab procedures
Appendix J Includes a list of sensory, motor, and mixed nerves that are useful for nerves conduction studies
Appendix K List procedure included in the CPT codebook that are not yet approved
Appendix L Is a reference of the vascular families, including which are considered first-, second-, and third-order vessels
Appendix M Shows a table of deleted CPT codes and crosswalks to current codes
Appendix N Is a listing of codes that have been re-sequenced
ICD-9-CM VOLUME 1 Tabular List of Disease and Injuries
ICD-9-CM VOLUME 2 The Alphabetic Index to Diseases and Injury
ICD-9-CM VOLUME 3 The Classification for Procedures for Reporting Hospital Procedures
HCPCS LEVEL 2 A codes Is Ambulance and transportation service, medical and surgical supplies
HCPCS LEVEL 2 B codes Is Enteral and parenteral therapy
HCPCS LEVEL 2 D codes Is Dental
HCPCS LEVEL 2 E codes Is Durable medical equipment
HCPCS LEVEL 2 G codes Is Procedures/professional service (temporary)
HCPCS LEVEL 2 J codes Is Drugs that are not self-administered (such as chemotherapy
HCPCS LEVEL 2 L codes Is Orthotic and prosthetic procedure
HCPCS LEVEL 2 M codes Office services and cardiovascular
HCPCS LEVEL 2 P codes Is Pathology
HCPCS LEVEL 2 Q codes Is Temporary codes
HCPCS LEVEL 2 R codes Is Domestic radiology
HCPCS LEVEL 2 V codes is Vision, hearing, and speech-language pathology service
Created by: kayymoore