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Chapter 04
Insurance Claims, Denied Claims and Appeals, and Credit and Collections
| Question | Answer |
|---|---|
| Claims management | completion, submission, and follow-up of claims for procedures and services provided. |
| Claims submission | the transmission of claims data (electronically or manually) to payers or clearinghouses for processing. |
| clearinghouse | agency or organization that collects, processes, and distributes health care claims after editing and validating them to ensure that they are error-free |
| explanation of benefits (EOB) | document sent to the patient by the third-party payer to provides details about the results of claims processing, such as provider charge, payer fee scheduled |
| remittance advice | electronic remittance advice (ERA) or standard paper remit (SPR) sent to providers by third-party payers that contains details about claims adjudication, including information about payments, deductibles and copayments |
| electronic flat file format | series of fixed-length records (e.g., 25 spaces for patient’s name) submitted to payers to bill for health care services. |
| Electronic data interchange (EDI) | computer-to-computer exchange of data between provider and payer. |
| ANSI ASC X12N | an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims. |
| Covered entities | private-sector health plans (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans |
| clean claim | a correctly completed standardized claim (e.g., CMS-1500 claim). |
| claims attachment | medical report substantiating a medical condition. |
| Coordination of benefits (COB) | provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies |
| Claims processing | sorting claims upon submission to collect and verify information about the patient and provider. |
| claims adjudication | comparing a claim to payer edits and the patient’s health plan benefits to verify that required information is available to process the claim |
| noncovered benefit | any procedure or service reported on a claim that is not included on the payer’s master benefit list, resulting in denial of the claim; also called noncovered procedure or uncovered benefit. |
| unauthorized services | services that are provided to a patient without proper preauthorization or that are not covered by a current preauthorization. |
| common data file | summary abstract report of all recent claims filed on each patient. |
| allowed charges | the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy. |
| beneficiary | the person eligible to receive health care benefits. |
| Downcoding | assigning lower-level codes than documented in the record. |
| Unbundling | submitting multiple CPT codes when one code should be submitted. |
| electronic remittance advice (ERA) | remittance advice that is submitted by the third-party payer to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly. |
| electronic funds transfer (EFT) | system by which payers electronically deposit funds to the provider’s (bank) account. |
| source document | the routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated. |
| Open claims | submitted to the payer, but processing is not complete. Open claims include those that were rejected (denied) |
| Closed claims | claims for which all processing, including appeals, has been completed. |
| Unassigned claims | generated for providers who do not accept assignment; organized by year. |
| Denied claims | claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues. |
| claims adjustment reason codes (CARC) | reason for denied claim as reported on the remittance advice or explanation of benefits. |
| remittance advice remark codes (RARC) | additional explanation of reasons for denied claims. |
| appeal | documented as a letter and signed by the provider, to explain why a claim should be reconsidered for payment. |
| pre-existing condition | any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee’s effective date of coverage. |
| peer review | appeal process that involves review of aby a medical reviewer (e.g., nurse) or a medical director (e.g., physician) |
| past-due account | one that has not been paid within a certain time frame (e.g., 120 days); also called delinquent account. |
| delinquent claims | claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due. |
| delinquent claim cycle | advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (e.g., 120 days or more). |
| accounts receivable aging report | shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. |
| outsource | contract out. |
| skip tracing | practice of locating patients to obtain payment of a bad debt; uses credit reports, databases, criminal background checks, and other methods. |
| bad debt | accounts receivable that cannot be collected by the provider or a collection agency. |
| Litigation | legal action to recover a debt; usually a last resort for a medical practice. |
Created by:
Amaya122000