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Ch18 Medical Billing
Chapter 18 Medical Billing & Reimbursement Essentials
Term | Definition |
---|---|
adjudicate | To settle or determine judicially. |
audit | A process completed before claims submission in which claims are examined for accuracy and completeness. |
capitation | A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her. |
claims clearinghouse | An organization that accepts the claim data from the provider, reformats the data to meet specifications outlined by the insurance plan, and submits the claim. |
claim scrubbers | Software that finds commom billing errors before the claim is sent to the insurance company. |
CMS-1500 Health Insurance Claim Form (CMS-1500) | The standard insurance claim form used for all government and most commercial insurance companies. |
copayment (copay) | A set dollar amount that the patient must pay for each office visit. |
eligibility | Meeting the stipulated reqirements to participate in the healthcare plan. |
endoscopy | Nonsurgical procedure that uses an endoscope to view inside the body. |
explanation of benefits (EOB) | A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for sevices, and the patient's financial responsibilities. |
medical necessity | Services or supplies (CPT and HCPCS codes) used to treat the patient's diagnosis (ICD codes) that meet the accepted standard of medical practice. |
National Provider Identifier (NPI) | An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties. |
precertification | The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure or service. |
provider Web portal | A secure online website that gives contracted providers a single point of access to insurance companies. |
release of information | A form completed by the patient that authorizes the medical office to release medical records to the insirance company for health insurance reimbursement. |