It's all about the "A"
Marking yes in box 27 on a CMS-1500 is a statement which tells the payer, the provider agrees to accept whatever payment is paid by the payer on a claim in full (except for any copayment and/or coinsurance). What is this called?
What is accept assignment?
This financial record source document is used by providers to record treated diagnoses and services rendered during the current encounter.
What is the "superbill" or "encounter form"
The process of sorting claims upon submission to collect and verify information about the patient and provider is referred to as ______ ________?
What is claims processing
This term refers to the amount for which the patient is financially responsible before an insurance policy provides coverage.
What is a deductible?
What does the abbreviation OOP stand for?
What is Out-of-pocket?
This is a documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment.
What is an appeal?
This is a provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.
What is a copayment (copay)?
A correctly completed standardized claim form
What is a "clean claim"
This term refers to the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
What is coinsurance?
What does the abbreviation COB stand for?
What is "Coordination of Benefits"?
What is the outstanding amount owed to the provider for services and/or goods provided referred to?
What is "A/R" (Accounts Receivable)
An unpaid claim returned by third-party payers because it fails to meet certain data requirements, such as missing data is referred to as a ___________ _______.
What is a claim rejection?
What do you call documentation such as medical records or authorizations forms that are submitted with a CMS-1500?
What is a "claim attachment"?
What is the term used to referer to the person responsible for paying the charges?
Who is the guarantor?
This is the long acronym for the electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental and drug claims.
What is ANSI (American National Standards Institute) ASC (Accredited Standards Committee) X12N (Insurance Subcommittee)
ANSI-ASC-X12N
This phrase represents the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy.
What is the allowed charge?
What is it called when the provider receives reimbursement directly from the payer?
What is the "assignment of benefits"?
What do you call the transmission of claims data electronically or manually to payers or clearinghouses for processing?
What is "claim submission"?
What do you call a claim for which all processing, including appeals, had been completed?
What is a closed claim?
What is the rule which states that the policyholder whose birth month and day occurs earlier in the calendar year is primary for a dependent who has coverage with both parents?
What is the "Birthday Rule"
This report shows the status by date of outstanding claims form each payer, as well as payments due from patients.
What is the "Accounts Receivable (A/R) Aging Report"
This must be met before a carrier will pay for services. It involves linking every procedure or service code reported on an insurance claim to a condition code (diagnosis) that justifies the need to perform the procedure.
What is Medical Necessity
This is what we call an unpaid claim returned by third-party payers because of beneficiary identification errors, coding errors, a diagnosis that does not support the medical necessity of procedures/service. duplicate claims, global days of surgery E/M coverage issues, NCCI edits, and other patient coverage issues such as services requiring preauthorization, a procedure not included in a patient's health plan contract, etc.
What is a claim denial?
What do you call a service that was provided to a patient without proper authorization or that are not covered by a current authorization?
What is an unauthorized service?
This is an abstract of all recent claims filed on each patient.
What is a common data file