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Rev Cycle Terminolog

CRCP testing

QuestionAnswer
835 File The ANSI standard electronic claims file for remittance processing. Includes payment, adjustment and denial information
837 File The ANSI standard electronic claims file for claims submission.
837I The 837 file format used for institutional charges
837P The 837 file format used for professional charges
ABN Advance Beneficiary Notice. A notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. If you do not get an ABN before you get the service from your doctor or su
Accept Assignment Claims can be submitted to an insurance carrier on either an assigned or non-assigned basis. Reimbursement is sent directly to the patient for non-assigned claims, and the provider must bill the patient for payment. If the claim is assigned, the provider
Accounts Receivable Accounts Receivable (AR) is the total of all balances owed by patients or insurance companies regardless of delinquency.
Acute Hospital acute care is recovery time after surgery or treatment of severe illness or injury that is taken care of in a hospital setting and is most often done by highly specialized personnel. The use of sophisticated and multifaceted technical equipment i
Adjustment Could be either credit or debit to the account.
Admission Date The date the patient was admitted for inpatient care, outpatient service, or start of care. For an admission notice for hospice care, enter the effective date of election of hospice benefits.
Admitting Physician The doctor responsible for admitting a patient to a hospital or other inpatient health facility.
Advanced Beneficiary Notice A Medicare form a patient can sign stating they understand that a particular service(s) might not be paid by Medicare thus making the service billable to the patient.
Allowed Charge The charge amount an insurance company considers being fair payment for a service or supply.
Allowed Days The number of days a patient is approved for medical services.
Ambulatory Ambulatory care is a type of medical care that is provided to patients who do not need to be admitted to a hospital for treatment. The types of procedures and treatments are sometimes referred to as “outpatient care.” As the “ambulatory” in the term would
Ambulatory Surgery Center ASC A place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, you may stay for only a few hours or for one night.
Ancillary Charges Charges associated with patient care, for example, x-rays, laboratory testing, etc., but they are not provided directly by the physician.
ANSI American National Standards Institute. An organization that acts as a national coordinator for voluntary communication standards in the United States. As a result of the HIPAA act all electronic claims must be submitted in the same ANSI format.
Applied Amount The portion of payment “applied” to a particular charge.
Attending Physician Number of the licensed physician who would normally be expected to certify and recertify the medical necessity of the number of services rendered and/or who has primary responsibility for the patient's medical care and treatment.
Authorization An authorization is the approval from the insurance company for the patient to have services performed. Most frequently, authorizations are required for specific procedures (i.e. MRI, surgery, rehab, therapy, etc). Authorizations are usually for a number
Authorization Number When required on a claim ensures payment for services rendered.
Balance Billing Billing a patient for charges above “allowable charge” paid by the health plan (i.e. the difference between billed charges and the plan’s allowable). Contracted providers are prohibited from balance billing for Medically Necessary Covered Services.
Beneficiary This is the person eligible to receive benefits under the health insurance policy; simply the patient.
Benefit Order The order in which the benefit falls (i.e. the primary health plan is listed in the first benefit order). See also Coordination of Benefits
Bill Type UB/1450 Type of Bill Code (Field 4) Three digit code that must be populated in field 4 of the 1450 indicating location of services. 1st digit = Type of Facility, 2nd digit = Bill Classifications and 3rd digit = Frequency. Also see:
Capitation A capitated plan or capitation is agreement between a primary care provider in which the provider is paid a set fee per patient each month by the insurance carrier to provide all medical care for each parent. The primary care provider will then ‘write off
Charge Ticket A hardcopy or electronic form used by a medical provider to mark procedures and diagnosis performed in their office or clinic. Also known as Super Bill, Encounter Form, Fee Slip, etc.
Claim A claim is a request for payment for services and benefits you received.
Clearinghouse An intermediary which receives electronic transaction from a provider/facility and either forwards the transactions along to payors or electronically or prints the claims/statements and mails to the appropriate parties.
CLIA Clinical Laboratory Improvement Amendment. A CLIA number is assigned to clinics that perform their own ‘in-house’ lab testing and when submitting lab charges, this number must be included on the claim form.
CMS Centers for Medicare and Medicaid Services (formerly known as HCFA). The Centers for Medicare and Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. See: www.cms.gov
COB Coordination of Benefits A plan to decide which insurance coverage will cover services when more than one type of coverage is present. Generally, this will be a primary and secondary coverage amount set on a procedure.
COBRA Consolidated Omnibus Budget Reconciliation Act of 1989 – A law that allows an individual the ability to purchase insurance coverage through an employers’ group health plan for an additional amount of time in specified conditions such as loss of employment
Coinsurance The percentage of the Private Fee-for-Service Plan charge for services that you may have to pay after you pay any plan deductibles. In a Private Fee-for-Service Plan, the coinsurance payment is a percentage of the cost of the service (like 20%).
Commercial Insurance A commercial insurance company does not participate with a government contract and rules vary by plan.
Compliance Program A compliance program helps demonstrate a practice or clinic’s good faith effort to comply with the laws and is designed to help identify and prevent erroneous and fraudulent claims, eliminate billing mistakes, reduce chance of audit and avoid arrangements
Coordination of Benefits A plan to decide which insurance coverage will cover services when more than one type of coverage is present. Generally, this will be a primary and secondary coverage amount set on a procedure.
Copay As per the insurance plan, “copay” is the amount the patient must pay for each visit to the provider. This is in addition to deductible amounts.
CPID (Common Processor Identifier) A four-digit identifier assigned to each specific payer by the clearinghouse, in order to facilitate payer recognition as applied to each electronic transaction.
CPT Current Procedural Terminology. CPT codes are a method, developed by the American Medical Association, for coding procedures and services performed by physicians. These procedure codes are updated annually in October and usually go into effect in January.
Credentialing The act of proving the credential of a healthcare provider. Generally this refers to verification of a physician’s state license, DEA (Drug Enforcement Agency) Number, Board Certification, Affiliation with certain organizations, etc.
Crossovers When a primary carrier will pass the claim and primary payment information on to the secondary carrier automatically, it is called a crossover or crossover claims. This is most common when Medicare is the primary payer.
Date of Service (DOS) The actual date in which the service or procedure was rendered by the provider.
DEA Drug Enforcement Agency – Administrative organization responsible for the authorizations to write prescriptions. A doctor needs a DEA number to write prescriptions.
Deductible The deductible is the amount the patient must pay before their insurance policy benefits begin. Denial- This is a term used when a service or procedure, usually covered by an insurance plan, will not be covered because the charges do not fall within the “
Diagnosis Code/DX A code that describes the illness or medical condition of a patient.
Discharge Date The date the patient was discharged from inpatient care, outpatient service, or start of care.
DME Durable Medical Equipment. Equipment needed for the care of a patient i.e. wheelchair, crutches, etc. Medicare requires charges for durable medical equipment to be submitted to a separate regional carrier. A separate claims form must be produced for these
DMERC Durable Medical Equipment Regional Carrier. There are four insurance carriers that process DME charges for Medicare. These carriers process claims for a certain region of the United States. The regional carrier to which DME claims are filed depends upon t
DRG Diagnosis Related Groups – A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG c
EBO (Extended Business Office) The Kansas City Acute Department responsible for completing extended and outsourced billing office agreements.
EDI Electronic Data Interchange – Transmission of claims and other information from one device to another.
EDI Translator A software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission.
Eligibility Status of patient's coverage with insurance carrier for medical procedures.
EMC Electronic Media Claims. There are claims submitted electronically via electronic transfer. Typically claims submitted electronically are processed more efficiently that paper claims. These claims are submitted in accordance with the ANSI standard 837 fil
EOB Explanation of Benefits – a payment for service provided for under an annuity pension plan, or insurance policy. An EOB is typically received by the patient and the practice, but another insurance company could potentially receive an EOB from another wher
EOD End of Day – Close of day charges, payments and adjustments.
EOM Close of month charges, payments and adjustment
EOMB Explanation of Medicare Benefits – A health care payment is usually accompanied by an EOMB paper or electronic statement. Payment or the lack of is explained for each item on a claim.
EPSDT Early Periodic Screening Development Testing. EPSDT is a federally funded f program that is administered by the state’s Medicaid programs. Physicians participating in this program are paid a set amount per patient for routine well child checks (or anyone
ERA Electronic remittance advice. The reception of claim payment information (EOB) via electronic data exchange.
Fee for Service Fee for service is the dollar amount charged by the physician for services performed.
Fee Schedule A fee schedule is a set dollar value for services and procedures performed. Fee schedules may be set by the clinic based upon what are reasonable and customary for the service or procedure. If the provider contracts with an insurance carrier, they would u
Form locator FL On each type of bill (HCFA 1450, or HCFA 1500) each field has a specific form locator that corresponds to a specific piece of data that is to be inserted into that field. For example the HCFA 1450 Form Locator 4 is the type of bill.
FQHC Federally Qualified Health Centers are private non profit or public organizations that receive federal grants from Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC) through section 330 of the Public Health Service A
Global Period A period of time during which post-operative or post-procedural services must be provided at no cost.
Group Number A Group number is a practice specific billing identifier.
Guarantor An individual who promises to pay the medical bill by signing a form of agreement to pay or who accepts treatment.
HCFA CMS 1450 The HCFA approved billing for typically reserved for institutional charges. This form is also commonly known as simply the “UB”. The uniform institutional claim form.
HCFA CMS 1500 The HCFA approved billing form, typically used for professional charges. This form is also known as the HCFA 1500 and is a standard form generally accepted by insurance carriers. Some payers may require different fields to be completed in different ways.
HCPCS HCFA Common Procedure Coding System. A coding method developed by HCFA to be used in billing for supplies, materials, and injections. HCPC codes are also used to bill procedures that are not defined by CPT codes. HCPC codes are used when billing, and are
Health Plan An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.
HIPAA The Health Insurance Portability and Accountability Act of 1996. This act includes two titles: Title I deals with what the legislation was initially designed to do, that is to provide guarantees that people do not lose insurance coverage when they switch
HL7 Health Level Seven is one of several ANSI – accredited Standards Developing Organizations (SDOs) operating in the healthcare arena. Most SDOs produce standards (sometimes called specifications or protocols) for a particular healthcare domain such as pharm
HMO Health Maintenance Organization. This organization is often set up with a network of primary care providers who serve as the gatekeepers for access to specialty providers of medical care services and/or supplies.
Hospitalist A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care
ICD-10 International Classification of Disease, 10th Revision Codes: Alphanumerical codes given to specify a patient's diagnosis. Although in use throughout Europe, these codes are not yet used in the United States. Tentative date of implementation is 10/2015
ICD-9 International Classification of Diseases. A method of coding clinical diagnoses. To submit insurance claims to an insurance carrier, a diagnosis code must accompany the CPT or HCPC code. ICD-9 codes are updated annually.
Institutional Charges Billings by inpatient hospital facilities, outpatient hospital facilities, nursing homes, home health agencies, etc. for medical procedures, goods, and services.
Insured Party The person who carries the insurance policy.
J-Codes A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to identify certain drugs and other items
Late Charge A charge that drops after a claim is submitted or transmitted
Major Medical An extended benefit contract designed to offset large medical expenses caused by prolonged illness or serious injury.
Managed Care An insurance coverage plan where the frequency and type of care provided to the patient is supervised and coordinated by a primary care physician in hopes of reducing health care costs. In most managed care programs, the patient may choose a primary care
Medicaid A federally aided, state-operated and administered program which provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program is authorized by Title XIX of the Social Security Act and covers only peo
Medicare A federal program that pays for certain health care expenses for people aged 65 or older. Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program. Medicare is less comprehensive than some other
Medicare Part A The Medicare Benefit plan that pays for inpatient hospital, Hospice, Nursing home care, Surgical Centers, Rural health charges.
Medicare Part B The Medicare benefit plan that pays for office, outpatient care, and DME charges.
Medicare Railroad An insurance plan designed for railroad workers and which is part of the railroad retirement act.
Medi-gap Medi-gap policies are offered by commercial insurance carriers to Medicare Patients. A Medi-gap policy fills in gaps in the Medicare’s coverage by paying for some charges Medicare does not cover.
Mnemonic (Client ID) An alpha or numeric identifier assigned to each Cerner client and their associated entities for billing purposes, tracking, and documentation.
Modifier A two-character code designed to give detail for a procedure code. Possible reasons for using a modifier include charging a less than standard fee, further describing a patient’s condition and describing the location of the treatment.
MSO A Management Service Organization. A MSO is a business that manages medical practices. There are a variety of MSO’s. A hospital may create (or sponsor) an MSO or a group of individuals may begin one. The MSO may have part ownership in the provider’s pract
MSP Medicare as Secondary Payer. Whenever Medicare is listed as a patient’s secondary carrier the clinic must indicate why Medicare is using a special MSP code.
NDC National Drug Code – A medical code set that identifies prescription drugs and some over the counter products and that has been selected for use in the HIPAA transactions. This number is a 10 o 11 digit number that refers to the drug.
Non Covered When the insurance carrier does not cover the procedure or service performed, it is deemed “not covered”.
Non Par Non-participating. The provider or group does not accept the insurance carrier’s fee schedule.
NPI (National Provider Identification Number) A ten-digit numeric identifier specifically assigned to an individual provider or group of providers, for recognition purposes regarding services rendered and billing.
Occ Med Occupational Medicine is when a provider group makes a business arrangement with an employer to provide medical services (such as drug screening, employment physicals, etc) for its employee. In this arrangement, the employer is the guarantor on the accoun
OCNA Other Carrier Name and address. A number assigned by Medicare to Medigap carriers. Medicare then uses this number (if identified on the claim form) to know to whom to send the Medicare Payment information for Medigap processing.
OHI Other Health Insurance
Open Item A charge which has a balance
Outlier Additions to a full episode payment in cases where costs of services delivered are estimated exceed a fixed loss threshold. HH PPS outliers are computed as part of Medicare claims payment by Pricer Software.
Par- Participating The provider or group accepts the carriers’ fee schedule and adjusts off any dollar amount over what is allowed per fee schedule. With Medicare a participating provider may decide to accept assignment on a case by case basis.
Payer ID A five-digit identifier (sometimes alpha-numeric) assigned to each payer by the NEIC (National Electronic Information Corporation) or the NAIC (National Association of Insurance Commissioners).
Payor Insurance company carrier, etc.
PHI Protected Health Information. Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. Identifies the individual or offers a reasonable basis for identificat
PHO Physician Hospital Organization is a formal alliance between physicians and a hospital. A PHO usually is formed to create a greater patient base and to gain a better position for Managed Care contracts.
Place of Service (POS) A one or two character code defining the type of facility where the services were rendered. A POS could represent a doctor’s office, hospital or laboratory. See also;
PPO Preferred Provider Organization. A PPO is a loose-knit organization of providers in which the insurer contracts with a limited number of physicians and hospitals to provide health care at specific levels of reimbursement for each service. While the patien
Practice Insight Cerner’s third-party vendor used to host the Revenue Manager application.
Preauthorization An approval from the particular authority (usually insurance company) before any action (treatment) is carried out.
Precertification Also known as preadmission certification is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain precertification may result in penalty to the provider or the subscriber.
Primary The insurance carrier that is first responsible for payment or services or procedures performed is called the Primary.
Professional Charge Component The reading, examination or interpretation of a specimen or procedure. Professional component services are identified with the modifier -26 and are normally payable to physicians or physicians’ groups.
Proration Proration is the process the system uses to calculate the expected payment for the different plans for a visit. Each Plan in the Plan Master has Proration set. If the Proration is set to 100%, the full payment is expected. If Proration is set for 80%, the
Provider The physician or other type of practitioner performing medical services.
Provider Number This is a code or number assigned per provider (doctor, nurse, physical therapist, etc.) by insurance carriers for identification purposes.
RA Remittance Advice
RAC Audits In order to identify and recoup perceived overpayments to healthcare providers nationwide, the Medicare Modernization Act of 2003 initially established the Medicare Recovery Audit Contractor (RAC) three-year demonstration program in Florida, New York and
RBRVS Resource Based Relative Value Scale (Medicare) RBRVS values are weights that are based on the time it takes to provide a service or perform a procedure. They also reflect the minimum training required provided a given service; this compensates providers f
RCM Revenue Cycle Management - RCM is a comprehensive approach that evaluates, improves, and manages all components in obtaining patient encounter information and applying it to ensure patient safety, while creating a simplified, integrated workflow designed
Reason Codes A national administrative code set that identifies the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the payer's payment for it. This code set is used in the X12 835 Claim Payment & Remittance
Recall A patient specific reminder to return to a clinic.
Red Flags A “Red Flag” is defined as a pattern, practice, or specific activity that could indicate identity theft. For instance, if a new patient completes the date of birth on a registration form with different information than that on his driver’s license that co
Referral A recommendation by a physician for a member to receive care from a participating specialist or facility.
Refile To refile is to resubmit a claim to an insurance carrier. Generally claims are refiled with additional information or after corrections are made to the claim.
Reject A reject is when the carrier refuses to pay for a claim. Insurance carriers generally provide a rejection code explaining why the claim was rejected. Rejected claims may be refilled with corrected information or with additional documentation.
Reprint The ability to reproduce reports, claims, or statements generated by the software. RES- Resource Scheduling System.
Reserve This is an amount the insurance carrier withholds from the provider for services rendered. At the end of the fiscal year the insurance carrier may reimburse the provider this amount.
Revenue Code Payment codes for services or items in FL 42 of the UB-92 found in Medicare and/or NUBC (National Uniform Billing Committee) manuals (42X, 43X, etc.)
Revenue Manager A web-based Cerner Transaction Service powered by Practice Insight, enabling clients to manage the entire cycle of their claims by utilizing parsed responses and reports, rejection management options, instant claims status check, and ERA evaluation (if ap
RHC Rural health Clinic – An outpatient facility that is primarily engaged in furnishing physicians' and other medical and health services and that meets other requirements designated to ensure the health and safety of individuals served by the clinic. The cl
RVU Relative Value Unit – A relative value unit is a numeric weight assigned to a medical encounter or procedure that provides information on its relative resource use.
CHIP Children’s Health Insurance Program Secondary – The insurance carrier responsible for the balance of the claim after the primary insurance carrier adjudication. When filing a secondary insurance carrier, the Explanation of Benefits from the primary insura
Scrubber A system that checks coding, bundling, and procedure information versus local Medicare and CCI Correct Coding Initiative edits/rules. This scrub assures better coding, identifies overlooked procedures or codes.
Shadow Claim Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.
Statements A form sent to the patient to inform the patient of the balance owed to the practice or clinic.
Submitter ID (Submitter Number) A six-digit unique client number created within the Navigator application by the ransaction Services Team, to be used by the clearinghouse for identifying clients in regards to their Transaction Services (claim submissions, responses, reports, and ERA’s).
Subscriber The insured policyholder or member who is protected in case of loss under the terms of an insurance policy. A policy might also include dependents of the insured.
Tax Identification Number A nine-digit number used by the federal government to identify an individual or business in regards to taxation
Taxonomy code A code issued by the CMS to classify a Providers Specialty. Typically the taxonomy code is 10 characters long.
Technical Component The physical part of attaining a specimen, performing procedure, or taking an x-ray. Technical component services are identified with the modifier --TC and are normally payable to facilities.
Tertiary The insurance carrier responsible for the claim after the secondary insurance carrier has completed its adjudication.
Timely Filing The timely filing restriction placed upon practices during which they must file a claim begins when the service is performed. If a practice waits beyond a certain period to file a claim, typically no payment will be received.
Triage A qualified nurse who function is to assess the medical status related to the patients immediate health needs.
Type of Service (TOS) Refers to a code that defines the type of service performed.
UB04 See HCFA 1450
Units To bill an insurance company for multiple quantities of a drug or procedure, a number of units must be included.
UPIN Universal Provider Identification Number. The UPIN is an alpha numeric character string assigned by HCFA to each physician who provides service for which Medicare payments are made. HCFA assigns one UPIN per physician despite the number of practices for w
Usual and Customary Means charges for medical services or supplies essential to the care of the Insured if they are the amount normally charged by the provider for similar services and supplies and do not exceed the amount ordinarily charged by most providers of comparable s
Workers Compensation An insurance plan carried by the patient’s employer that covers job related injuries or illnesses. These charges cannot be billed to the patient.
Utilization Review embedded partners Interqual or Milliman (MCG)
Discharge Planning embedded partners NaviHealth (formerly Curaspan) or Ensocare
CDI (Clinical Documentation Integrity) embedded partner Nuance Clintegrity
Cerner internal clearinghouse HDX (healthcare data exchange) which is from Siemens
Medical Necessity Checking embedded partner Optum is the only embedded partner. Experian is advanced MNC
Scrubbers embedded partners nThrive, SSI, Alpha
2 types of claim forms CMS 1500 and UB-04
difference between CPT codes and ICD codes CPT codes are related to procedures and ICD codes are related to diagnoses
Benchmarking comparing yourself across other like clients
KPIs business metric used to evaluate factors that are crucial to the success of an organization. KPIs differ per organization
DNFB Discharged, not final billed- Will be measured in days and dollars. (and drill down to reasons)
Address Validation embedded partner USPS
Address Verification embedded partner Experian
Eligibility embedded partner Emdeon
Patient Statements partner Apex
Post Acute Providers Skilled Nursing Facility (SNF), Home Health, Hospice, Long Term Acute Care Hospital (LTACH), Durable Medical Equipment (DME)
6 major govt health care programs Medicare, medicaid, childrens health insur program CHIP, TRICARE, DOD TRICARE, VHA - or CHAMPVA for the VA , indian health services HIS
Title XIX of the Social Security Act Coverage: Low Income Families, Pregnant Women, People of all ages with Disabilities, People who need long term care Wealthier states have smaller share of cost reimbursed by federal government. Expansion under Accountable Care Act
Created by: shawndecker71