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Medical Billing Key Terms

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Question
Answer
accounting cycle   the flow of financial transactions in a business  
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accounts receivable   monies that are flowing into a business  
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adjudication   series of steps that determine whether a claim should be paid  
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billing cycle   regular schedule of sending statements to patients  
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capitation   advance payment to a provider that covers each plan member's health care services for a certain period of time  
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coding   a way of translating a description of a condition into a shorter, standardized code  
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coinsurance   part of charges that an insured person must pay for health care services after payment of the deductible amount  
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consumer-driven health plan (CDHP)   a type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit  
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copayment   a small fixed fee paid by the patient at the time of an office visit.  
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diagnosis   physician's opinion of the nature of the patient's illness or injury  
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diagnosis code   a standardized value that represents a patient's illness, signs, and symptoms.  
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encounter form   a list of the procedures and charges for a patient's visit.  
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explanation of benefits (EOB)   paper document from a payer that shows how the amount of a benefit was determined  
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fee-for-service   health plan that repays the policyholder for covered medical expenses  
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Health Maintenance Organization (HMO)   a managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan  
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health plan   a plan, program, or organization that provides health benefits  
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managed care   a type of insurance in which the carrier is responsible for both the financing and the delivery of health care  
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medical coder   a person who analyzes and codes patient diagnoses, procedures, and symptoms  
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medical necessity   treatment provided by a physician to a patient for the purpose fo preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice.  
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patient information form   form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim  
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payer   private or government organization that insures or pays for health care on the behalf of the beneficiaries  
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policyholder   a person who buys an insurance plan; the insured  
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practice management program (PMP)   a software program that automates many of the administrative and financial tasks required to run a medical practice  
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Preferred Provider Organization (PPO)   managed care network of health care providers who agree to perform services for plan members at discounted fees  
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premium   the periodic amount of money the insured pays to a health plan for insurance coverage  
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procedure   medical treatment provided by a physician or other health care provider  
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procedure code   a code that identifies a medical service  
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remittance advice (RA)   an explanation of benefits transmitted electronically by a payer to a provider  
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statement   a list of all services performed for a patient, along with the charges for each service.  
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