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week 4

chapter 16-17

What is an Explanation of Benefits Notification sent by insurance carrier to the patient and provider after a claim has been processed.
Define adjudication Steps that result in an insurance carrier's decision to either pay or deny a claim
How should you appeal for reconsideration of a carrier's decision in writing
What does the State Insurance Commissioner do state official who has regulatory control over insurance carriers and can assist with disputes
Who is the Explanantion of Benefits sent to provider and patient
What are the two main methods used by providers to determine their fees charge-based and resource-based fee structures
Who updates the Medical Conversion factor annually The Center for Medicare and Medicaid CMS
Define Nonparticipating provider A nonparticipating provider who is able to balance-bill for the amount over carrier's allowed charges
Define withhold Percentage of the provider's payment that is not paid during a contract year but is kept by the health plan to offset additional costs including for references, hospital admission, or other covered services
Under most insurance plans when does the deductible apply to each covered individual calendar year
What is peer review An objective, unbiased group of physicians that determines what payment for services
Who may ask the state insurance commissioner to help in resolving a payment dispute patients, physician, insurance carriers
Define documentation The chronological recording of pertinent facts and observations regarding a patient's health status
What does SOAP stand for Subjective, Objective, Assessment, and Plan
Where can the medical office specialist learn about insurance carrier's appeal process Administrative manual or newsletters from the carriers, or call the carrier
What is the low that protects the interest of beneficiaries enrolled on private employee benefit plans ERISA
How long does a qualified independent contractor have to process a reconsideration 60 days
How long does Medicare have to process a redetermination 30 days
To take a Medicare appeal to the level of decision by an administrative law judge, the claim must be a minimum of what amount $130
Define disallowance A provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charges.
Created by: vpolosukhina
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