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MOP 130

insurance claims

accept assignment provider accepts as payment in full whatever is paid on the claim by the payer
accounts receivable the amount owed to a business for services or goods provided
accounts receivable aging report shows the status 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; such as insurance verifications/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 electronic format standard that uses a variable length file format to process transactions for institutional, professional, dental, and drug claims
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 the payer
bad debt account 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 contains computer generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient account system, and charges are automatically posted to the patient's bill(UB-04)
claims 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; claim's not a duplicate; payer rules and procedures have been followed; procedures performed. services prov
claims attachment 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 to payers or clearinghouses for processing
clean claim a correctly completed standardized claim (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 also called 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 on each patient
Consumer Credit Protection Plan Act of 1968 considered landmark legislation, launched truth in lending disclosures that required creditors to communicate the cost of borrowing money in common language, consumers could figure out charges, compare cost, shop for best credit deal
coordination of benefits (COB) provisions in health insurance policies that 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 plans, managed care organizations, ERISA covered health benefit plans, and governmental health plans, clearinghouses, and all health care providers that choose to submit/receive transactions electronically
day sheet called manual daily accounts receivable journal; chronically summary of all transactions posted to individual patient ledgers/ accounts on a specific day
deductible amount for which the patient is financially responsible before an insurance policy provides coverage
delinquent account account that has not been paid in a certain time frame
delinquent claim claim more that n 120 days past due
delinquent claim cycle advances through various aging periods
downcoding assigning lower level codes than documented in the record
electronic data interchange (EDI) computer to computer exchange of data between provider and payer
electronic flat file format series of fixed length records 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 Healthcare Network Accreditation Commission (EHNAC) organization that accredits clearinghouses
electronic media claim series of fixed self records submitted to payers to bill for health care services
electronic remittance advice ( ERA) remittance advice that is submitted to the provider electronically and contains same information as a paper based remittance advice; providers receive 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, sec, marital status, age, receipt of public assistance, or good faith exercise of any rights under the Consumer Credit Protection Plan
guarantor person responsible for paying health care fees
litigation legal action to recover a debt; usually 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; also called noncovered procedure or uncovered benefit
nonparticipating provider 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
participating provider
past due account
patient account record -
patient ledger
pre existing condition
primary insurance
secondary insurance
source document
two party check
unassigned claim
unauthorized service
value added network
Created by: watson14