Help
Options
Question
ACCEPT ASSIGNMENT
click to flip
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't know
Question
ACCOUNTS RECEIVABLE
Remaining cards (64)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
CHAPTER 4
PROCESSING AN INSURANCE CLAIM-HEALTH INS BOOK
| Question | Answer |
|---|---|
| ACCEPT ASSIGNMENT | PROVIDER ACCEPTS AS PAYMENT IN FULL WHATEVER IS PAID ON THE CLAIM BY THE PAYER(EXCEPT FOR ANY COPAYMENT AND/OR COINSURANCE AMOUNTS) |
| ACCOUNTS RECEIVABLE | AMOUNT OWED TO A BUSINESS FOR SERVICES OR GOODS PROVIDED |
| ACCOUNTS RECEIVABLE AGING REPORT | SHOWS THE STATUS (BY DATE) OF OUTSTANDING CLAIMS FROM EACH PAYER, AS WELL AS PAYMENTS DUE FROM PATIENTS |
| ACCOUNTS RECEIVABLE MANAGEMENT | ASSISTS PROVIDERS IN THE COLLECTION OF APPROPRIATE REIMBURSEMENT FOR SERVICES RENDERED; INCLUDE FUNCTIONS SUCH AS INSURANCE VERIFICATION/ELIGIBILITY & PREAUTHORIZATION OF SERVICES |
| ALLOWED CHARGE | MAXIMUM AMOUNT THE PAYER WILL REIMBURSE FOR EACH PROCEDURE OR SERVICE, ACCOURDING TO THE PATIENT'S POLICY |
| ANSI ASC X12 STANDARDS | USE A VARIABLE-LENGTH FILE FORMAT TO PROCESS TRANSACTIONS FOR INSTITUTIONAL, PROFESSIONAL, DENTAL, AND DRUG CLAIMS |
| APPEAL | DOCUMENTED AS A LETTER, SIGNED BY THE PROVIDER, EXPLAINING WHY A CLAIM SHOULD BE RECONSIDERED FOR PAYMENT |
| ASSIGNMENT OF BENEFITS | THE PROVIDER RECEIVES REIMBURSEMENT DIRECTLY FROM THE PAYER |
| BAD DEBT | ACCOUNTS RECEIVABLE THAT CANNOT BE COLLECTED BY THE PROVIDER OR A COLLECTION AGENCY |
| BENEFICIARY | THE PERSON ELIGIBLE TO RECEIVE HEALTHCARE BENEFITS |
| BIRTHDAY RULE | DETERMINES COVERAGE BY PRIMARY AND SECONDARY POLICIES WHEN EACH PARENT SUBSCRIBES TO A DIFFERNT HEALTH INSURANCE PLAN |
| CHARGEMASTER | TERM HOSPITALS USE TO DESCRIBE A PATIENT ENCOUNTER FORM |
| CLAIMS ADJUDICATION | COMPARING A CLAIM TO PAYER EDITS AND THE PATIENT'S HEALTH PLAN BENEFITS TO VERIFY THAT THE REQUIRED INFORMATION IS AVAILABLE TO PROCESS THE CLAIM; THE CLAIM IS NOT A DUPLICATE |
| CLAIMS ATTACHMENT | MEDICAL REPORT SUBSTANTIATING A MEDICAL CONDITION |
| CLAIMS PROCESSING | SORTING CLAIMS UPON SUBMISSION TO COLLECT AND VERIFY INFORMATION ABOUT THE PATIENT AND PROVIDER |
| CLAIMS SUBMISSION | THE TRANSMISSION OF CLAIMS DATA (ELECTRONICALLY OR MANUALLY)TO PAYERS OR CLEARINGHOUSES FOR PROCESSING |
| CLEAN CLAIM | A CORRECTLY COMPLETED STANDARDIZED CLAIM (E.G., CMS-1500 CLAIM) |
| CLEARINGHOUSE | PERFORMS CENTRALIZED CLAIMS PROCESSING FOR PROVIDERS AND HEALTH PLANS |
| CLOSED CLAIM | CLAIMS FOR WHICH ALL PROCESSING, INCLUDING APPEALS, HAS BEEN COMPLETED |
| COINSURANCE- COINSURANCE PAYMENT | PERCENTAGE THE PATIENT PAYS FOR COVERED SERVICES AFTER THE DEDUCTIBLE HAS BEEN MET AND THE COPAYMENT HAS BEEN PAID |
| COMMON DATA FILE | ABSTRACT OF ALL RECENT CLAIMS FILED ON EACH PATIENT |
| CONSUMER CREDIT PROTECTION ACT OF 1968/TRUTH IN LENDING ACT | CONSIDERED LANDMARK LEGISLATION BECAUSE IT LAUNCHED TRUTH-IN-LENDING DISCLOSURES THAT REQ'D CREDITORS TO COMMUNICATE THE COST OF BORROWING MONEY IN A COMMON LANGUAGE SO THAT CONSUMERS COULD FIGURE OUT THE CARGES, COMPARE COSTS,SHOP FOR BEST CREDIT DEAL |
| COORDINATION OF BENEFITS (COB) | PROVISION IN GROUP HEALTH INSURANCE POLICIES THAT PREVENTS MULTIPLE INSURERS FROM PAYING BENEFITS COVERED BY OTHER POLICIES;ALSO SPECIFIES THE COVERAGE WILL BE PROVIDED IN A SPECIFIC SEQUENCE WHEN MORE THAN ONE POLICY COVERS THE CLAIM |
| COVERED ENTITY | PRIVATE SECTOR HEALTH PLANS, MANAGED CARE ORGANIZATIONS, ERISA-COVERED HEALTH BENEFIT PLANS AND GOVERNMENT PLANS; ALL HEALTHCARE CLEARINGHOUSES;AND ALL HEALTHCARE PROVIDERS WHO CHOOSE TO SUBMIT OR RECEIVE TRANSACTIONS ELECTRONICALLY |
| DAY SHEET | "MANUAL DAILY ACCOUNTS RECEIVABLE JOURNAL" CHRONOLOGICAL SUMMARY OF ALL TRANSACTIONS POSTED TO INDIVIDUAL PATIENT LEDGERS/ACCOUNTS ON A SPECIFIC DAY |
| DELINQUENT ACCOUNT- PAST DUE ACCOUNT | ONE THAT HAS NOT BEEN PAID WITHIN A CERTAIN TIME FRAME (E.G., 120 DAYS) |
| DELINQUENT CLAIM | 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, 60, 90 DAYS, AND SO ON) WITH PRACTICES TYPICALLY FOCUSING INTERNAL RECOVERY EFFORTS ON OLDER DELINQUENT ACCOUNTS (E.G., 120 DAYS OR MORE) |
| DOWNCODING | ASSIGNING LOWER-LEVEL CODES THAN DOCUMENTED IN THE RECORD |
| ELECTRONIC CLAIMS PROCESSING | SENDING DATA IN A STANDARDIZED MACHINE-READABLE FORMAT TO AN INSURANCE COMPANY VIA DISK, TELEPHONE, OR CABLE |
| ELECTRONIC DATA INTERCHANGE (EDI) | COMPUTER-TO-COMPUTER EXCHANGE OF DATA BETWEEN PROVIDER AND PAYER |
| ELECTRONIC FLAT FILE FORMAT | SERIES OF FIXED-LENGTH RECORDS (E.G., 25 SPACES FOR PATIENT'S NAME) SUBMITTED TO PAYERS TO BILL FOR HEALTHCARE SERVICES |
| ELECTRONIC FUNDS TRANSFER (EFT) | SYSTEM BY WHICH PAYERS DEPOSIT FUNDS TO THE PROVIDER'S ACCOUNT ELECTRONICALLY |
| ELECTRONIC FUNDS TRANSFER ACT | ESTABLISHED THE RIGHTS, LIABILITIES, AND RESPONSIBILITIES OF PARTICIPANTS IN ELECTRONIC FUNDS TRANSFER SYSTEMS |
| ELECTRONIC HEALTHCARE NETWORK ACCREDITATION COMMISSION (EHNAC) | ORGANIZATION THAT ACCREDITS CLEARINGHOUSES |
| ELECTRONIC MEDIA CLAIM | ELECTRONIC FLAT FILE FORMAT |
| ELECTRONIC REMITTANCE ADVICE (ERA) | REMITTANCE ADVICE THAT IS SUBMITTED TO THE PROVIDER ELECTRONICALLY AND CONTAINS THE SAME INFO. AS A PAPER-BASED REMITTANCE ADVICE; PROVIDERS RECEIVE THEM MORE QUICKLY |
| ENCOUNTER FORM | FINANCIAL RECORD SOURCE DOCUMENT USED BY PROVIDERS AND OTHER PERSONNEL TO RECORD TREATED DIAGNOSES AND SERVICES RENDERED TO THE PATIENT DURING THE CURRENT ENCOUNTER |
| EQUAL CREDIT OPPORTUNITY ACT | PROHIBITS DISCRIMINATION ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, MARITAL STATUS, AGE, RECEIPT OF PUBLIC ASSISTANCE, OR GOOD FAITH EXERCISE OF ANY RIGHTS UNDER THE CONSUMER CREDIT PROTECTION ACT |
| FAIR CREDIT & CHARGE CARD DISCLOSURE ACT | AMENDED THE TRUTH IN LENDING ACT, REQUIRING CREDIT & CHARGE CARD ISSUERS TO PROVIDE CERTAIN DISCLOSURES IN DIRECT MAIL, TELEPHONE, & OTHER APPLICATIONS & SOLICITATIONS FOR OPEN-END CREDIT &CHARGE ACCOUNTS;LAW APPLIES TO PROVIDERS THAT ACCEPT CREDIT CARDS |
| FAIR CREDIT BILLING ACT | FEDERAL LAW PASSED 1975 THAT HELPS CONSUMERS RESOLVE BILLING ISSUES WITH CARD ISSUERS; PROTECTS IMPORTANT CREDIT RIGHTS, INCLUDING RIGHTS TO DISPUTE BILLING ERRORS, UNAUTHORIZED USE OF AN ACCOUNT, AND CHARGES FOR UNSATISFACTORY GOODS AND SERVICES |
| FAIR CREDIT REPORTING ACT | PROTECTS INFO. COLLECTED BY CONSUMER REPORTING AGENCIES SUCH AS CREDIT BUREAUS, MEDICAL INFORMATION COMPANIES AND TENANT SCREENING SERVICES; |
| FAIR DEBT COLLECTION PRACTICES ACT (FDCPA) | SPECIFIES WHAT A COLLECTION SOURCE MAY AND MAY NOT DO WHEN PURSUING PAYMENT OF PAST DUE ACCOUNTS |
| GUARANTOR | PERSON RESPONSIBLE FOR PAYING HEALTHCARE FEES |
| LITIGATION | LEGAL ACTION TO RECOVER A DEBT; USUALLY A LAST RESORT FOR A MEDICAL PRACTICE |
| MANUAL DAILY ACCOUNTS RECEIVABLE JOURNAL/DAY SHEET | A CHRONOLOGICAL SUMMARY OF ALL TRANSACTIONS POSTED TO INDIVIDUAL PATIENT LEDGERS/ACCOUNTS ON A SPECIFIC DAY |
| NONCOVERED BENEFIT- NONCOVERED PROCEDURE-UNCOVERED 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 THE CLAIM; |
| NONPARTICIPATING PROVIDER (NONPAR) | DOES NOT CONTRACT WITH THE INSURANCE PLAN; PATIENTS WHO ELECT TO RECEIVE CARE FROM THESE PROVIDERS WILL INCUR HIGHER OUT-OF-POCKET EXPENSES |
| OPEN CLAIM | SUBMITTED TO THE PAYER, BUT PROCESSING IS NOT COMPLETE |
| OUT-OF-POCKET PAYMENT | ESTABLISHED BY HEALTH INSURANCE COMPANIES FOR A HEALTH INSURANCE PLAN; USUALLY HAS LIMITS OF $1,000 TO $2,000;WHEN THE PATIENT HAS RECEACHED THE LIMIT OF PAYMENT(E.G., ANNUAL DEDUCTIBLE)FOR THE YEAR, APPROPRIATE PATIENT REIMBURSEMENT IS DETERMINED |
| OUTSOURCE | CONTRACT OUT |
| PARTICIPATING PROVIDER (PAR) | CONTRACTS WITH A HEALTH INSURANCE PLAN AND ACCEPTS WHATEVER THE PLAN PAYS FOR PROCEDURES OR SERVICES PERFORMED |
| PAST-DUE ACCOUNT - DELINQUENT ACCOUNT | ONE THAT HAS NOT BEEN PAID WITHIN A CERTAIN TIME FRAME (E.G., 120 DAYS) |
| PATIENT ACCOUNT RECORD/PATIENT LEDGER | A COMPUTERIZED PERMANENT RECORD OF ALL FINANCIAL TRANSACTIONS BETWEEN THE PATIENT AND THE PRACTICE |
| PREEXISTING 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 |
| PRIMARY INSURANCE | ASSOCIATED WITH HOW AN INSURANCE PLAN IS BILLED- THE INSURANCE PLAN RESPONSIBLE FOR PAYING HEALTHCARE INSURANCE CLAIMS FIRST IS CONSIDERED PRIMARY |
| PROVIDER REMITTANCE NOTICE (PRN) | REMITTANCE ADVICE SUBMITTED BY MEDICARE TO PROVIDERS THAT INCLUDES PAYMENT INFORMATION ABOUT A CLAIM |
| SOURCE DOCUMENT | THE ROUTING SLIP, CHARGE SLIP, ENCOUNTER FORM, OR SUPERBILL FROM WHICH THE INSURANCE CLAIM WAS GENERATED |
| SUPERBILL | TERM USED FOR AN ENCOUNTER FORM IN THE PHYSICIAN'S OFFICE |
| SUSPENSE | PENDING |
| TWO-PARTY CHECK | CHECK MADE OUT TO BOTH PATIENT AND PROVIDER |
| UNASSIGNED CLAIM | GENERATED FOR PROVIDERS WHO DO NOT ACCEPT ASSIGNMENT; ORGANIZED BY YEAR |
| UNAUTHORIZED SERVICE | SERVICES THAT ARE PROVIDED TO A PATIENT WITHOUT PROPER AUTHORIZATION OR THAT ARE NOT COVERED BY A CURRENT AUTHORIZATION |
| UNBUNDLING | SUBMITTING MULTIPLE CPT CODES WHEN ONE CODE SHOULD BE SUBMITTED |
| VALUE-ADDED NETWORK (VAN) | CLEARINGHOUSE THAT INVOLVES VALUE-ADDED VENDORS, SUCH AS BANKS, IN THE PROCESSING OF CLAIMS; USING A VAN IS MORE EFFICIENT AND LESS EXPENSIVE FOR PROVIDERS THAN MANAGING THEIR OWN SYSTEMS TO SEND AND RECEIVE TRANSACTIONS DIRECTLY FROM NUMEROUS ENTITIES |
Created by:
Tina Everett