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NHA CBCS Exam
Review Material
| Term | Definition |
|---|---|
| Accounts Receivable | Amount owed to a provider |
| Revenue Cycle Management | Manage financial viability by increasing revenue, improving cash flow, from registration to final payment. |
| Basic Steps for Revenue Cycle | Registration and Scheduling Patient Check In Utilization Management Review Healthcare Encounter & Documentation Charge Capture and Coding Patient Check out Billing Payer Adjudication Receiving & Posting Reimbursement App |
| Copayment | Flat, fixed fee paid by the patient at the time of an office visit. |
| Assignment of Benefits | patient's written authorization giving the insurance company the right to pay the physician directly for billed charges. |
| Beneficiary | Person eligible to receive benefits for covered health care services rendered. |
| Eligibility | Process of verifying the patient has insurance coverage and has benefits for the services to be provided. |
| Out-of-Pocket Payment | The amount paid personally for health services. |
| Coinsurance | Predetermined % that the patient is responsible to pay for covered services once the annual deductible has been met. |
| Deductible | Annual amount the patient must pay before the insurance will begin to pay for covered benefits. Restarts every calendar year |
| Utilization Management | A method used to control health care cost by reviewing the appropriateness and medical necessity of services rendered to the patients prior to the treatment being performed. |
| Preauthorization | Prior authorization from a payer for services to be provided. (e.g., laboratory or imaging services, hospitalizations, surgical procedure). |
| Medical Necessity | A process insurance companies use to verify whether or not a procedure was medically necessary to treat the patients complaint/problem. |
| Encounter Form | A document used to collect data about elements of a patient visit that can become part of a patient record or be used for management purposes. |
| Appeals Process | A process used to request reconsideration of a claim that was denied. Determine if denial was due to an error. |
| Fair Debt Collection Practices Act (FDCPA) | Specifies what a collection source may and may not do when pursuing payment of past due accounts. |
| Non-covered Services | Services that are not payable by the health plan. |
| Preferred Provider Organization (PPO) | A health care plan that contracts with health care professionals to provide services at a reduced fee and gives patients financial incentives to use network providers. |
| What is the difference between In-Network and Out-of-Network providers? | In-network providers have signed a contract with an insurance company. The providers agree to accept a set amount for services provided called allowed charges. They also agree to write off any balances above the defined patient responsibili |
| Capitation | An agreement with providers to receive a pre-established payment for health care services to enrollees over a period of time. |
| Medicare | National Health Insurance program for the elderly and disabled. |
| Medicaid | Federal program that provides medical benefits for low-income persons. |
| Medicare Plan A | Reimburses organization for impatient hospital, skilled nursing facility, hospice, and some home health services. |
| Medicare Plan B | A fee-for-service plan that reimburses for provider and professional services, outpatient hospital care, and durable medical equipment. |
| Medicare Plan C | The option to choose a managed care plan, which reimburses providers for all the same benefits as traditional Medicare and additional services such as vision and dental. |
| Medicare Part D | The prescription medication benefit. |
| Coordination of Benefits (COB) | Defines the order of responsibility for claims when there is more than one payer. |
| What is used to prevent multiple insurance plans from overpaying on services and procedures? | Coordination of Benefits |
| Timely Filing | When the organization is required to submit a claim to the insurance plan for services. Typically ranging from 30 days-12 months. |
| Timely Limit For Medicare & TRICARE | 360 days- 1 year from date services were rendered. |
| Timely Limit For Commercial Plans Like BCBS | 120 days from date services were rendered or the date of discharge from the hospital. |
| In-Network | A provider who has signed an agreement with the insurance plan. Accepted assignments for services rendered. |
| Out-of-Network | A provider who does not have a signed agreement with an insurance plan. Has not accepted assignments with insurance company for services rendered. Typically patient pays higher out-of-pocket expenses when using out-of-network provider. |
| Premium | Monthly amount the policyholder pays each month to receive plan benefits. |
| Covered Benefits | Services outlined in the policy that are payable by the health plan. Includes visits to primary care provider (PCP) or specialists, diagnostic and laboratory testing, and preventive services. |
| Health Maintenance Organization (HMO) | A group of contracted providers that agree to the payment contract for its members. |
| What is a way third-party insurance plans keep medical costs down? | Preauthorization |
| A patient receives a gastric bypass surgery in March and the yearly deductible has been met by this claim. After the procedure, the maximum out-of-pocket amount has also been met for the year. The patient presents to the office in June for joint | $0 |
| 3 CPT Categories (Cate. 1 Divided into 6 sections) | Category I: (Largest) Surgery Category II: Supplemental Tracking Codes used to collect data for reporting performance measurements. Category III: Temporary Codes used to report emerging technology and experimental medical procedures and services. |
| 99202-99499 | Evaluation & Management (E/M) |
| 00100-01999 | Anesthesia |
| 10004-19499 | Integumentary |
| 20100-29999 | Musculoskeletal |
| 30000-32999 | Respiratory |
| 33016-39599 | Cardiovascular |
| 40490-49999 | Digestive |
| 50010-60699 | Urinary, Male & Female Genital |
| 61000-64999 | Nervous |
| 65091-69990 | Eye/Ocular Adnexa, Auditory & Operating Microscope |
| 70010-79999 | Radiology |
| 90281-99607 | Medicine |
| Bullet Symbol | New Code |
| Triangle Symbol | Revised Code |
| Mirrored Sideways Triangles | Contains New or Revised Text |
| Plus Symbol | Add on code |
| Circle With Line Through It | Exemption from the use of modifier -51 |
| Lightning Rod Symbol | FDA Approved Pending |
| Hashtag Symbol | Resequenced Code |
| Star Symbol | Telemedicine |
| )( Symbol | Duplicate PLA (proprietary laboratory analysis) test |
| What is the term for surgical Removal of the ovaries? | Oophorectomy |
| NEC | Meaning "Other Specified" |
| NOS | Meaning "Unspecified" |
| Parentheses ( ) | Enclosed nonessential modifiers or supplementary words. |
| Brackets [ ] | Enclose a code assignment for a manifestation. |
| -oma | Tumor |
| Hypo- | Deficient, Below |
| -centesis | Puncture a cavity for fluid removal. |
| Diplo- | Double |
| Cellulitis | Subcutaneous inflammation of cellular or connective tissue |
| Septicemia | Invasion of the bloodstream by bacteria, viruses, or fungi from an infection. |
| Otitis | Inflammation of the ear |
| Prolapsing | A condition that occurs when an internal organ slips from its normal position. |
| Query | Contacting the responsible provider to request clarification about documented diagnosis or procedures. |
| 835 | Electronic transmission of RA/EOB |
| Electronic Funds Transfer (EFT) | A computer-based transfer of money. Refers to an organization receiving reimbursement from a third-party payer. |
| Age Report | A report that shows the length of outstanding balance in the system. |
| Payer Mix | The showing of a % of usage under a specific payer. |
| National Uniform Claim Committee (NUCC) | Provides guidelines for each block of the CMS-1500 form. |
| 837P | The electronic version of the professional claim form. |
| What is the correct date format for entering DOB on a claim according to NUCC? | 02202021 (MMDDYYYY) |
| CMS-1500 Form | The paper version of the claim and provide the payer with necessary identifying information of the patient and the servicing provider, such as patient demographics; date of service; insurance ID number; and service provided. |
| Appeal | The official process of requesting a review of a claim that was underpaid or denied. |
| Medicare Administrative Contractor (MAC) | A third-party payer that has been contracted to process Medicare Part A and Part B medical claims for Medicare Fee-For-Services (FFS) beneficiaries. |
| Redetermination | The process through which your Medicaid patients report their household income to the local County Department of Job and Family Services (CDJFS) every 12 months to redetermine their eligibility for Medicaid. Filed with the Medicare Administrative Contract |
| Reconsideration | A request for review of a claim that a provider feels was incorrectly paid or denied because of processing errors. Filed with the qualified independent contractor (QIC) in writing. |
| Disposition by Office of Medicare Hearings and Appeals (OMHA) | Filed with HHS OMHA by telephone or video teleconference. In some cases, can be in person. |
| Review by the Medicare Appeals Council (Council) | Filed with the council in writing. |
| Judicial review in U.S. District Court | Filed in a district court according to the details provided by the Council's response. |
| Medical Ethics | Standards of conduct based on moral principals. Acting within ethical behavior boundries means carrying out one's responsibilities with integrity, decency, respect, honesty, competence, fairness and trust. |
| Chief Complaint (CC) | The reason the patient came to see the physician. |
| Modifier 50 | Bilateral procedure |
| Modifier 24 | Attach to E/M service code when service is provided during postoperative period to indicate the the service is not part of postoperative care and not included in the Surgical Package |
| Modifier 26 | Provider only provided the professional component |
| Modifier 51 | Used more than on procedure during the same surgical episode |
| Modifier 57 | Modifier 57 is used on E/M services the day before or day of major surgery when the initial decision to perform the surgery is identified. |
| Modifier 78 | Physician must return to Operating Room to address complication stemming from initial procedure |
| Modifier 79 | Procedure or service provided during postoperative period not associated with initial procedure. |
| ABN / Advance Beneficiary Notice | a notice that a doctor, supplier, or provider gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment. |
| Remittance Advice | The explanation of payments received from the insurance company. |
| Clearinghouse | A group that takes nonstandard medical billing software formats and translates them into the standard Electronic Data Interchange (EDI) formats. |
| Liability Insurance | Covers injuries caused by insured that occurred on the insured's property. |
| According to the Example Medicare Premiums chart, what is the monthly premium for an individual who has an income of $125,000 on the tax return? | $297.00 |
| -GA | Is used when both covered and non-covered services appear on an ABN-related claim. |
| -GX | Report when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded or is not a Medicare benefit. You may use this modifier combined with modifier -GY. |
| -GY | Report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. You may use this modifier combined with modifier -GX. |
| -GZ | Report when you expect Medicare to deny payment of the item or service because it is medically unnecessary and you issued no ABN. |
| According to Medicare, a patient who has diabetes mellitus should receive a hemoglobin A1c blood test once every 3 months. More frequent testing should only be performed when medically necessary. What modifier would be reported if the specialist does not | -GA |
| Patient A sees the physician three times this month. Patient B has been healthy and has not seen the physician at all this month. The physician is paid a capitation rate of $35 per month. What is the reimbursement for patient A and Patient B for the month | Patient A $35, Patient B $35 |
| Unbundling | Using multiple CPT codes to report individual components of the documented procedure. |
| Upcoding | Reporting a higher-level service or procedure or a more severe diagnosis than is supported by the provider’s documentation. |
| Downcoding | A lack of relevant or detailed information in the provider’s documentation to assign a code for the optimal level of service, procedure, or diagnosis. |
| Batch Claim Report | Summarizes claim details including patient, payer, and date of transmission. |
| Scrubber Report | A clearinghouse summary of the number and total amount of claims. |
| Transaction Transmission Summary | Displays the status of claims as accepted or rejected. |
| Rejection Analysis Report | Identifies the most common errors by batch |
| Patient Demographic Errors Including Zip Code Format | Must include 9 digits. |
| Billing Organization Address | Post office boxes are not allowed. |
| National Drug Codes | Drug quantity and unit of measure must be reported. |
| Protected Health Information (PHI) | Requires a patient's authorization prior to disclosure. |
| CPT Guidelines | The specialist must be able to identify the correct start/stop times to code the claim correctly. |
| Privacy | A patient's right to have their protected health information safe guarded and not disclosed to others without their permission. |
| Medicare Recovery Audit Contractor (RAC) | Can review medical records to investigate potential improper Medicare payment, such as overpayments or underpayments. |
| Office of Inspector General (OIG) | Identify Medicare fraud and abuse, and then sending those cases to the department of Justice for prosecution. |
| The Defense Enrollment Reporting System (DEERS) | The insurance eligibility reporting system for service members and their families. Verify the patients third party payer eligibility. |
| Patient Covered Under 2 Group Insurance Plans | The patients own plan is primary while the patients partner's plan is secondary. |
| -itis | Inflammation |
| IT | Route in which a medication is introduced into the subdural space of the spinal cord. |
| Claim Adjustment Reason Code (CARC) | Identifies the reason for a claim denial. |
| 80/20 Coinsurance | Allowed Amount x 20% (0.20)= Coinsurance |
| Stop-Loss | The insurer is liable for any losses that go over a set employer deductible limit. |
| Write-Off | The form of not billing the insured for certain services that exceed the allowable costs set in place by the insurance company. |
Created by:
Jadarush0
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