To settle or determine judicially.

A process completed before claims submission in which claims are examined for accuracy and completeness.

A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her.

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.

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.

A set dollar amount that the patient must pay for each office visit.

Meeting the stipulated reqirements to participate in the healthcare plan.

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.

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.

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.

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.

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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.

Created by: maggiemaew

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