Question 1

aging

Accepted Answer

Classification of AR by the length of time an account is due.

Question 2

appeal

Accepted Answer

A request sent to a payer for reconsideration of a claim adjudication.

Question 3

appellant

Accepted Answer

One who appeals a claim decision.

Question 4

autoposting

Accepted Answer

Software feature that enables automatic entry of payments on a remittance advice to credit an individual’s account.

Question 5

claim adjustment group code (CAGC)

Accepted Answer

Code used by a payer on an RA to indicate the general type of reason code for an adjustment.

Question 6

claim adjustment reason code (CARC)

Accepted Answer

Code used by a payer on an RA to explain why a payment does not match the amount billed.

Question 7

claimant

Accepted Answer

Person or entity exercising the right to receive benefits.

Question 8

Glossary
claim status category codes

Accepted Answer

Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending.

Question 9

claim status codes

Accepted Answer

Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry.

Question 10

claim turnaround time

Accepted Answer

The time period in which a health plan is obligated to process a claim.

Question 11

concurrent care

Accepted Answer

Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service.

Question 12

determination

Accepted Answer

A payer’s decision about the benefits due for a claim.

Question 13

development

Accepted Answer

Payer process of gathering information in order to adjudicate a claim.

Question 14

electronic funds transfer (EFT)

Accepted Answer

Electronic routing of funds between banks.

Question 15

explanation of benefits (EOB)

Accepted Answer

Document sent by a payer to a patient that shows how the amount of a benefit was determined.

Question 16

grievance

Accepted Answer

Complaint by a medical practice against a payer filed with the state insurance commission by a practice.

Question 17

HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)

Accepted Answer

The electronic transaction for payment explanation.

Question 18

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)

Accepted Answer

The standard electronic transaction to obtain information on the status of a claim.

Question 19

insurance aging report

Accepted Answer

A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days.

Question 20

medical necessity denial

Accepted Answer

Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria.

Question 21

Medicare Outpatient Adjudication (MOA) remark codes

Accepted Answer

Remittance advice codes that explain Medicare payment decisions.

Question 22

Medicare Redetermination Notice (MRN)

Accepted Answer

Communication of the resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal.

Question 23

Medicare Secondary Payer (MSP)

Accepted Answer

Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries’ claims.

Question 24

overpayment

Accepted Answer

An improper or excessive payment resulting from billing errors to a provider as a result of billing or claims processing errors for which a refund is owed by the provider.

Question 25

pending

Accepted Answer

Claim status during adjudication when the payer is waiting for information from the submitter.

Question 26

prompt-pay laws

Accepted Answer

Regulations that obligate payers to pay clean claims within a certain time period.

Question 27

reassociation trace number (TRN)

Accepted Answer

Identifier that is passed from the payer to the payer’s bank, then to the practice’s bank, and finally to the practice.

Question 28

reconciliation

Accepted Answer

Comparison of two numbers to determine whether they differ.

Question 29

redetermination

Accepted Answer

First level of Medicare appeal processing.

Question 30

remittance advice (RA)

Accepted Answer

Health plan document describing a payment resulting from a claim adjudication; the copy sent to the insured is called an explanation of benefits (EOB).

Question 31

remittance advice remark code (RARC)

Accepted Answer

Code that explains payers’ payment decisions.

Question 32

suspended

Accepted Answer

Claim status during adjudication when the payer is developing the claim.

MED112 CODE/BILL

MED112 KEY TERMS CH 13

Question	Answer
MED112 CH 13 KEY TERMS
aging	Classification of AR by the length of time an account is due.
appeal	A request sent to a payer for reconsideration of a claim adjudication.
appellant	One who appeals a claim decision.
autoposting	Software feature that enables automatic entry of payments on a remittance advice to credit an individual’s account.
claim adjustment group code (CAGC)	Code used by a payer on an RA to indicate the general type of reason code for an adjustment.
claim adjustment reason code (CARC)	Code used by a payer on an RA to explain why a payment does not match the amount billed.
claimant	Person or entity exercising the right to receive benefits.
Glossary claim status category codes	Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending.
claim status codes	Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry.
claim turnaround time	The time period in which a health plan is obligated to process a claim.
concurrent care	Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service.
determination	A payer’s decision about the benefits due for a claim.
development	Payer process of gathering information in order to adjudicate a claim.
electronic funds transfer (EFT)	Electronic routing of funds between banks.
explanation of benefits (EOB)	Document sent by a payer to a patient that shows how the amount of a benefit was determined.
grievance	Complaint by a medical practice against a payer filed with the state insurance commission by a practice.
HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835)	The electronic transaction for payment explanation.
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)	The standard electronic transaction to obtain information on the status of a claim.
insurance aging report	A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days.
medical necessity denial	Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria.
Medicare Outpatient Adjudication (MOA) remark codes	Remittance advice codes that explain Medicare payment decisions.
Medicare Redetermination Notice (MRN)	Communication of the resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal.
Medicare Secondary Payer (MSP)	Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries’ claims.
overpayment	An improper or excessive payment resulting from billing errors to a provider as a result of billing or claims processing errors for which a refund is owed by the provider.
pending	Claim status during adjudication when the payer is waiting for information from the submitter.
prompt-pay laws	Regulations that obligate payers to pay clean claims within a certain time period.
reassociation trace number (TRN)	Identifier that is passed from the payer to the payer’s bank, then to the practice’s bank, and finally to the practice.
reconciliation	Comparison of two numbers to determine whether they differ.
redetermination	First level of Medicare appeal processing.
remittance advice (RA)	Health plan document describing a payment resulting from a claim adjudication; the copy sent to the insured is called an explanation of benefits (EOB).
remittance advice remark code (RARC)	Code that explains payers’ payment decisions.
suspended	Claim status during adjudication when the payer is developing the claim.

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