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Chapter 4

Payment Adjudication

TermDefinition
accounts receivable department department that keeps track of what 3rd party payers provide on what patients are due
explanation of benefits (EOB) describes the services rendered, payments covered benefits and denials
CPT/HCPCS codes must correspond to the description of the service
aging report measures the outstanding balances in each account
charge description master (CDM) Information about health care services that patients have received and financial transactions
Age trial balance (ATB) refers to the status of an invoice aging reports often maintained in 30-day increments
Assessing the Status Accounts aging reports help the staff see which accounts have not been paid by checking the EOB or RA to tell why patient has an outstanding balance
account number number that identifies specific episodes of care for date of service(DOS)
health record number number the provider uses to identify an individual patient's record
Medicare summary notice(MSN) document that outlines the amounts billed by the provider and what the patients pay the provider
Remittance Advice(RA) the report sent from the third party payer to the provider
subscriber purchaser of the insurance or the member of group for which an employer or associations as purchased insurance
subscriber number unique code used to identify a subscriber's policy
cost sharing the balance the policyholder must pay to the provider
batch a group of submitted claims
balance billing billing patients for charges in excess of the Medicare fee schedule
managing denials important to track denials when payments are posted tracked by payer type of denials and provider
affordable care act how patients can appeal health insurance decisions
External Independent if claim is still denied internal appeal patient can request an external independent review
Created by: K.Lindsey