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CBCS Exam definition

Abstracting the extraction of specific data from a medical record, often for use in and external database, such as a cancer registry
Abuse practices that directly or indirectly result in unnecessary costs to the Medicare program
Account number number that identifies specific episode of care, date of service, or patient
Accounts receivable department department that keeps track of what third-party payers the provider is waiting to hear from and what patients are due to make a payment
Activity/status date indicates the most recent activity of an item
Actual charge the amount the provider charges for health care service
Administration Simplification Compliance Act (ASCA) specifically prohibits any payment by Medicare for services or medically necessary supplies that are not submitted electronically
Administrative services only (ASO) contract contract between employers and private insurers under which employers fund the plans themselves, and the private insurers administer the plans for the employers
Advance Beneficiary Notice of Noncoverage form provided if a provider believes that a service may be declined because Medicare might consider it unnecessary
Aging report measures the outstanding balances in each account
Allowable charge the amount an insurer will accept as full payment, minus applicable cost sharing
APC grouper helps coders determine the appropriate ambulatory payment classification (APC) for an outpatient encounter
Assignment of benefits contract in which the provider directly bills the payer and accepts the allowable charge
Auditing review of claims for accuracy and completeness
Authorization permission granted by the patient or the patient's representative to release information for reasons other than treatment, payment or health care operations
Balance billing billing patients for charges in excess of the Medicare fee schedule
Batch a group of submitted claims
Blue Cross/Blue Shield Plan the first prepaid plan in the U.S. that offers health insurance to individuals, small businesses, seniors, and large employer groups
Business associate (BA) individuals, groups, or organizations who are not members of a covered entity's workforce that perform the functions or activities on behalf of or for a covered entity
Capitation the fixed amount a provider receives
Case management review of clinical services being performed
Category I CPT codes codes that covers physicians' services and hospital outpatient coding
Category II CPT codes codes designed to serve as supplemental tracking codes that can be used for performance measurement
Category III CPT codes codes used for temporary coding for new technology and services that have not met the requirements needed to be added to the main section of the CPT book
Charge amount the amount the facility charges for the procedure or service
Charge description master (CDM) information about healthcare services that patients have received and financial transactions have taken place
Charge or service code internally assigned number unique to each facility
Claim a complete record of services provided by a healthcare professional, along with appropriate insurance information, submitted for reimbursement to a third-party payer
Claims adjustment reason code (CARC) provides financial information about claims decisions
Claim scrubber software that reviews a claim prior to submission for correct and complete data, such as accurate gender in alignment with diagnosis/procedure or medical necessity
Clean claim claim that is accurate and complete. They have all the information needed for processing, which is done in a timely fashion
Clearinghouse agency that converts claims into a standardized electronic format, looks for errors, and formats them according to HIPAA and insurance standards
Clinical documentation the record of clinical observations and care a patient receives at a health care facility
Commercial innsurance private and employer-based self-insurance
Computer-assisted coding (CAC) software that scans the entire patient's electronic record and codes the encounter based on the documentation in the record
Conditional payment Medicare payment that is recovered after primary insurance pays
Consent a patient's permission evidenced by signature
Contractual obligation used when a contractual agreement resulted in an adjustment
Coordination of benefits rules determines which insurance plan is primary and which is secondary
Correction and renewal used for correcting a prior claim
Cost sharing the balance the policyholder must pay to the provider
Crossover claim claim submitted by people covered by a primary and secondary insurance plan
De-identified information information that does not identify an individual because unique and personal characteristics have been removed
Demographic information date of birth, sex, marital status, address, telephone number, relationship to subscriber, and circumstances of condition
Description of service an evaluation and management visit, observation, or emergency room visit
Diagnosis code International Classification of Diseases (ICD-10-CM)
Dirty claim claim that is inaccurate, incomplete, or contains other errors
Electronic data interchange (EDI) the transfer of electronic information in a standard format
Employer-based self-insurance insurance that is tied to an individual's place of employment
Encoder software that suggests codes based on documentation or other input
Encounter a direct, professional meeting between a patient and a health care professional who is licensed to provide medical services
Encounter form form that includes information about past history, current history, impatient record, discharge information, and insurance information
Explanation of benefits (EOB) describes the services rendered, payment covered, and benefit limits and denials
Fair Debt Collection Practices Acts (FDCPA) debt collectors cannot use unfair or abusive practices to collect payments
False Claims Act protects the government from being overcharged for services provided or sold, o substandard goods or services
Final Rule strengthens the HIPAA ruling around privacy, security, breach notification, and penalties
Formulary a list of prescription drugs covered by an insurance plan
Fraud making false statements of representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist
Gatekeeper provider who determines the appropriateness of the health care service, level of health care professional called for, and setting for care
General ledger key two-or three-digit number that makes sure that a line item is assigned to the general ledger in the hospital's accounting system
Group code code that identifies the party financially responsible for a specific service or the general category of payment adjustment
Group or plan number unique code used to identify a set of benefits of one group of type of plan
Group practice model HMO that contracts with an outside medical group for services
Health Insurance Portability and Accountability Act (HIPAA) of 1996 legislation that includes Title II, for the first parameters designed to protect the privacy and security of patient information
Health maintenance organization (HMO) plan that allows patients to only go to physicians, other healthcare professionals, or hospitals on al ist of approved providers, except in an emergency
Health record number number the provider uses to identify an individual patient's record
ICD-10-CM coding and classification system that captures diseases and health-related conditions. Developed by the World Health Organization (WHO) and adapted to the U.S. healthcare system for uses that include securing reimbursement for services provided
ICD-10-PCS coding and classification system developed for use in the U.S. only. Specific to inpatient hospital procedures
Implied consent a patient presents for treatment, such as extending an arm to allow a venipuncture to be performed
Independent practice association (IPA) model HMO that contracts with the IPA, which in turn contracts with individual health providers
Individually identifiable documents that identify the person or provide enough information so that the person could be identified
Informed consent providers explain medical or diagnostic procedures, surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided
Managed care organization organization developed to manage the quality of healthcare and control costs
Medicaid a government-based health insurance option that pays for medical assistance for individuals who have low incomes and limited financial resources. Funded at the state and national level. Administered at the state level
Medical necessity the documented need for a particular medical intervention
Medicare Administrative Contractor (MAC) processes Medicare Parts A and B claims from hospitals, physicians, and other providers
Medicare Advantage (MA) combined package of benefits under Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage
Medicare federally funded health insurance provided to people age 65 or older, people younger than 65 who have certain disabilities, and people of all ages with end-stage kidney disease. Funded and administered atthe national level
Medicare Part A provides hospitalization insurance to eligible individuals
Medicare Part B voluntary supplemental medical insurance to help pay for physicians' and other medical professionals' services, medical services, and medical-surgical supplies not covered by Medicare Part A
Medicare Part D a plan run by private insurance companies and other vendors approved by Medicare
Medicare specialty plan plan that provides focused, specialized healthcare for specific groups of people, such as those who have both Medicare and Medicaid, live ina long-term care facility, or have chronic medical conditions
Medicare Summary Notice (MSN) document that outlines the amounts billed by the provider and what the patient must pay the provider
Medigap a private health insurance that pays for most of the charges not covered by Parts A and B
Modifier additional information about types of services, and part of valid CPT or HCPCS codes
Morbidity the number of cases of disease in a specific population
Mortality the incidence of death in a specific population
MS-DRG grouper software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity of the illness or injury, and other factors
National Provider Identifier (NPI) unique 10-digit code for providers required by HIPAA
Network model HMO that contracts with two or more independent practices
Notice of Exclusions from MEdicare Benefits notification by the physician to a patient that a service will not be paid
Ordering provider a physician or other licensed healthcare professional (e.g., physician assistant, nurse practitioner) who prescribes services for a patient
Other adjustment used when no other code applies to the adjustment
Out-of-network not contracted with the health plan
Out-of-pocket maximum a predetermined amount after which the insurance company will pay 100% of the cost of medical services
Patient responsibility the amount the patient owes
Preauthorization the health plan is notified that a hospital stay or significant procedure is coming up, giving the plan the opportunity to determine if it is medically necessary and, in an inpatient admission, how many days the patient most likely will need to stay
Precertification a review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting
Predetermination a written request for verification of benefits
Preferred Provider Organization (PPO) plan that allows patients to use physicians, specialists, and hospitals in the plan's network
Preferred provider Tier II provider
Primary insurance insurance that pays first, up to the limits of its coverage
Prior approval number number indicating that the insurance company has been notified and has approved services before they are rendered
Privacy Rule a HIPAA rule that establishes protections for the privacy of individual's health information
Private-fee-for-service plan plan that allows patients to go to any physician, other healthcare professional, or hospital as long as the providers agree to treat those patients
Private insurance health care subsidized through premiums paid directly to the company
Procedure code ICD procedure codes (ICD-10-PCS), Current Procedural Terminology (CPT) codes, of Healthcare Common Procedures Coding System (HCPCS) that represents the procedure or service
Protected health information (PHI) individually identifiable health information
Provider-level adjustment reason code codes that are not related to a specific claim
Referral written recommendation to a specialist
Referring provider the physician or other licensed healthcare professional who requests a service for a patient
Reimbursement payment for services rendered from a third-party payer
Remittance advice (RA) the report sent from the third-party payer to the provider that reflects any changes made to the original billing
Remittance advice remark code (RARC) code that explains the reason for a payment adjustment
Revenue code four-digit code that identifies specific accommodation, ancillary service, or billing calculation related to services on a bill
Staff model HMO that provides hospitalization and physician services through its own staff
Stark Law physicians are not allowed to refer patients to a practitioner with whom they have a financial relationship
State Children's Health Insurance Program (SCHIP) a program jointly funded by the federal government and the states
Subscriber number unique code used to identify a subscriber's policy
Subscriber purchaser of the insurance or the member of the group for which an employer or association as purchased insurance
Supervising provider the physician monitoring a patient's care
Third-party payer organization other than a patient who pays for services, such as insurance companies, Medicare, ans Medicaid
Tier 1 providers and facilities in a PPO's network
Tier 2 providers and facilities within a broader, contracted network of the insurance company
Tier 3 providers and facilities out of the network
Tier 4 providers and facilities not on the formulary
Timely filing requirement within 1 calendar year of a claim's date of service
UB-04 code three-digit code that describes a classification of a product or service provided to the patient
Unbundling using multiple codes that describe different components of a treatment instead of using a single code that describes all steps of the procedure
Upcoding assigning a diagnosis or procedure code at a higher level than the documentation supports, such as coding bronchitis as pneumonia
Utilization review a process used to determine the medical necessity of a particular procedure or service, designed to ensure that the procedure or service is appropriate and is being provided in the most cost-effective way
Write-off the difference between the provider's actual charge and the allowable charge
Created by: crystal_r
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