study guide
Help!
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| Patients can be billed for___________ but not _________. | non-covered procedures
unauthorized services
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| Guarantor | Person responsible for paying the charges
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| when does the development of an insurance claim begin? | When the providers office completes and submits the CMS-1500 form
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| the check in procedure for a patient who is new to the providers office is __________ than a returning patient. | More extensive
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| Claims attachment | supporting documentation or information that is associated with a healthcare claim or patient encounter
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| it is necessary to submit a claims attachment when using an | unlisted CPT code
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| accept assignment | the provider agrees to accept what insurance allows or approves as payment in full for the claim
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| CMS-1500 form requires responses to standard questions pertaining to: | auto accident: secondary insurance and employment (among other things)
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| clean claim | contains all required data elements needed to process and pay the claim
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| what do you need to know to process a claim | Name and phone number of the third party payer and the name of the policy holder (among other things)
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| SOF | signature on file can be submitted as patient signature as long as the signature is on file in the office.
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| CMS-1500 form is used to ............. | report professional and technical services
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| If a payer marks a claim with "pending" status, | the provider can respond by correcting errors and omissions on the claim and resubmit for reconsideration
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| appeal | a letter signed by the provider explaining why a claim should be reconsidered for payment
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| PAR: Participating Provider | contracts with a health insurance plan and accepts whatever the plan pays for procedures and services performed.
The PAR is not allowed to bill the patients for the difference (called balance billing).
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| Encounter Form | the financial record source document used by healthcare providers to record treated diagnoses and services rendered to the patient during the encounter
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| Clearing houses process claims that are filed in a ____________ and _________. | "flat" format
converted to a "standard" format
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| The birthday rule | a policy determination for covered children
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| what happens when children are covered by the insurance policy of both parents? | The birthday rule says the parents whose birthday month and day come first int he calender year holds the primary policy.
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| Day sheet | chronological summary of all transactions posted on a specific day
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| Before scheduling an appointment with a specialist, | a managed care patient must obtain a referral form their PCP or Case Manager
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| Gender Rule | states the father's plan is always primary when the child is covered by both parents
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| Primary insurance is the insurance plan... | responsible for paying health care insurance claims first
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| what are SOAP notes used for? | they are used in providers offices to document patients visits
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| What does the health information specialist have the patient do when arriving at the doctor's office? | Have the patient complete a patient registration form
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| Patient Account Record | computerized record of all financial transactions between patients and the pratice
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| Generate a separate __________ and __________ for each patient to maintain each type of information. | financial record and medical record
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| claim attachment | supporting documentation associated with a healthcare claim for patient encounter
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| The patient account record is also called the | patient ledger
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| electronic flat file | clearinghouse claims processing format
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| What two things are used by healthcare providers to record services and diagnoses rendered during the visit? | superbill and encounter form
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| chargemaster | hospital financial record source document
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| NonPAR is a physician who is..... | NOT contracted with an insurance company
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| Modifier | reported on claims to provide clarification about procedures and services performed
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| VAN | Value-added Network; clearinghouse that involves vendors like banks, in the processing of claims
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| examples of covered entities | Private sector health plans
Managed Care Organizations
ERISA-covered benefit plans
Government health plans
Healthcare clearinghouses
Providers that submit or receive claims electronically
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| _________ insurance pays first and ________________pays after that. | Primary
Secondary
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