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INSURANCE
Nationals
| Question | Answer |
|---|---|
| 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
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