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ch.4 key terms
understanding health insurance
| Question | Answer |
|---|---|
| accept assignment | provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/ or coinsurance amounts). |
| accounts receivable | the amount owed to a business for services or goods provided. |
| accounts receivable aging report | shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. |
| accounts receivable management | assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verification/ eligibility and preauthorization of services. |
| allowed charges | the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy. |
| ANSI ASC X12 | an electric format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claim. |
| appeal | documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. |
| assignment of benefits | the provider receives reimbursement directly from payers. |
| bad debt | accounts receivable that cannot be collected by the provider or a collection agency. |
| beneficiary | the person eligible to receive health care benefits. |
| birthday rule | determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. |
| chargemaster | document that contains a computer generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04) |
| claim adjudication | comparing a claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicate; payer rules and procedures has been followed; and procedures/services covered. |
| claims attachments | medical report substantiating a medical condition. |
| claims processing | sorting claims upon submission to collect and verify information about the patient and provider. |
| claims 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 ) |
| clearinghouse | performs centralized claims processing for providers and health plans. |
| closed claim | claims in which all processing, including appeals, has been completed. |
| coinsurance | also called coinsurance payment; the percentage the patients pays for covered services after deductible has been met and the copayment has been paid. |
| common data file | abstract of all recent claims filed on each patient. |
| consumer credit protection act of 1968 | was considered landmark legislation because it launched truth-in- lending disclosure that required creditors to communicate the cost of borrowing money in common language so that consumers could figure out the charges, compare cost, and shop bets deal. |
| coordination of benefits (COB) | provision in group health insurance policies that prevents multiple insurers from paying benefits covered by 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 plans managed care organizations(excludes small self-administered health plans), ERISA-covered health benefit plans , and government health plans( includes Medicare, Medicaid, military health system . |
| day sheet | also called manual daily accounts receivable journal; chronological summary of all transcription posted to individual patient ledgers/accounts on a specific day. |
| deductible | amount for which the patient is financially responsible before the insurance policy provides coverage. |
| delinquent account | (see past due account) |
| delinquent claim | claim usually more than 120 days past due; some practices establish more time frames that are less than or more than 120 days past due. |
| 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 (e.g., 120 days or more). |
| downcoding | assigning lowered-level codes than documented in the record. |
| electronic data interchange (EDI) | computer-to-computer exchanged exchange of data between provider and payer. |
| electronic flat file format | series of fixed-length records (e.g., 25 spaces for patient's name ) submitted to payers to bill for health care services. |
| electronic funds transfer (EFT) | system by which payers deposit funds to the provider's account electronically. |
| Electronic funds transfer act | established the rights, liabilities, and responsibilities of participants in electronic funds transfer system. |
| electronic health care network accreditation commission (EHNAC) | organization that accredits clearing houses. |
| electronic media claim | (electronic flat file format) series of fixed-length records (e.g., 25 spaces for patient's name ) submitted to payers to bill for health care services. |
| 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. |
| encounter form | financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. |
| Equal credit opportunity act | prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age receipt of public assistance, or good faith exercise of any rights under the Consumer Credit protection. |
| fair credit and charge card disclosure act | amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosure in the direct mail, telephone, and other applications and solicitation for open-end credit and charge accounts and under other circumstances |
| fair credit billing act | federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory goods and service. |
| fair credit reporting act | protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services. |
| 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 health care fees. |
| litigation | laws. |
| 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,; also called noncovered procedure or uncovered benefit. |
| nonparticipanting provider (nonPAR) | does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses. |
| open claim | submitted to the payer, but processing is not complete. |
| out-of-pocket payment | established by the health insurance companies for a health insurance plan; Usually has a limit of 1,000 or 2,000; when the patient has reached the limit of an out of pocket payment (e.g. annual deductibles) for the year, appropriate patient reimbursement. |
| outsource | contract out |
| participating provider (PAR) | contracts with a health insurance plan and accepts whatever plan pays for procedures or services performed. |
| past-due account | one that has not been paid within a certain time frame (e.g. 120 days); also called delinquent account . |
| patient account record | also called patient ledger; a computerized permanent record of all financial transactions between the patient and the practice. |
| patient ledger | (see patient account records )a computerized permanent record of all financial transactions between the patient and the practice |
| pre-existing condition | any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage. |
| primary insurance | associated with how an insurance plan is billed-the insurance plan responsible for paying health care insurance claims first is considered primary. |
| provider remittance notice (PRN) | remittance advice submitted by Medicare to providers that includes payment information about a claim. |
| secondary insurance | billed after primary insurance has paid contracted amount. |
| source of document | the routing slip, charged 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 | (see consumers Credit Protection act of 1968) |
| two-party check | check made out both patient and provider. |
| unassigned claim | generated for providers who do not accept assignment; organized by year. |
| unauthorized service | services that are provided to a patient without proper authorization or that are not covered by current authorization. |
| unbundling | submitting multiple CPT codes when one code should be submitted. |
| 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 the providers than managing their own systems to send and receive transactions directly from #us entities. |
Created by:
mariaparra
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