Hospital Terms
Healthcare facility that provides same-day surgical services to persons needing less than 24 hours of nursing/medical care.
What is an "Ambulatory Surgery Center"?
A digital version of a patient’s paper chart.
What is an "Electronic Health (Medical) Record"?
Government health insurance program for Americans who are 65 years of age or older or individuals on disability.
What is "Medicare"?
This is a type of managed care plan that is a hybrid of HMO and PPO plans. Like an HMO, participants designate an in-network physician as their primary care provider. Like a PPO, patients my go outside of the provider network to get healthcare services.
What is a "Point of Service (POS) plan"?
Charges accumulating on a patient’s claim who is still receiving inpatient services and hasn’t been discharged
What are "In-House" charges?
A metric for measuring the percentage of claims having no defects or special circumstances (among all claims submitted) and therefore gets through the claim scrubber and sent to the payer. A clean claim does not guarantee that the payer will pay.
What is the "Clean Claim or Validation Rate" (CCR)?
A file with Institutional claims sent to a payer.
What is the "837I" file?
HFMA
What is the "Healthcare Financial Management Association"?
The 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization
What is the ICD10?
A hospital specializing in treating patients that require extended hospitalization.
What is a "LTAC"?
A shared instance of larger EMRs (Epic, Cerner, etc.) that certain hospital systems can provide to smaller regional facilities. Often available at a lower cost but limited in customization options.
What is a "Community Connect"?
Supplemental health insurance for Medicare.
What is "Medigap"?
This is a Medi-Cal form that provides for pre-approval of funding for treatment.
What is a "Treatment Authorization Request (TAR)"?
When hospitals will hold a bill for a period of 3-7 days to allow departments to get their charges in.
What are "Bill Hold Days"?
A calculation that is made by taking the total dollar amount of claims that have been denied by payers within a given time period and then dividing it by the total dollar amount of claims submitted within the same time.
What is the "Denial Rate"?
A file with Professional claims sent to a payer.
What is the "837P" file?
AAHAM
What is the acronym for the "American Association of Healthcare Administrative Management"?
A listing of every item, service or procedure that a hospital could provide.
What is the "Chargemaster" (CDM)?
This is a designation given to eligible rural hospitals by CMS and was put in place to reduce the financial vulnerability of rural hospitals
• 25 or fewer acute care inpatient beds
• Located more than 35 miles from another hospital
What is a "Critical Access Hospital" (CAH)?
A subsystem of a hospital information system that is used for storing financial data, calculation healthcare costs, and providing billing information.
What is a "Patient Accounting System" (PAS)?
Hospitalization period between day 61-90 days, the patient is responsible for part of these costs.
What are "Medicare Coinsurance Days"?
This is a responsible party and/or insured party who is not necessarily the patient.
What is a "Guarantor"?
Hospital bills that have completed service but have not been billed to insurance yet
What is "Discharged Not Final Billed" (DNFB)?
Charges that cannot be collected from patients. It is typically written off and sent to a collection agency.
What is "Bad Debt"?
A transaction set is the electronic version of an Application Advice document. Used to notify the sender of a previous transaction that the document has been accepted, or to report on errors.
What is the "824" file?
MGMA
What is the acronym for the "Medical Group Management Association"?
A bill that uses several commonly used ICD-10 codes for reflecting rendered services.
What is a "Superbill"?
The prices that hospitals get paid from Medicare for certain services.
Prospective Payment System (PPS)
A software product that provides claim scrubbing services and submits electronic healthcare claims to payers. Clearinghouses electronically transmit claim information that is compliant with HIPAA standards.
What is a "Clearinghouse"?
Refers to an entity or a private company that has a contract with CMS to determine and to pay part A and some Part B bills, such as bills from hospitals, on a cost basis and to perform other related functions.
What is a "Fiscal Intermediary" (FI)?
This is sometimes required by patient’s insurance company to determine medical necessity, does not guarantee benefits will be paid.
What is "Pre-Certification"?
Tracking of dollars not yet submitted to payers. Claims are tracked to make sure they are submitted to meet filing requirements, measured by how many "days" of revenue are sitting in the total unbilled.
What is "Unbilled A/R"?
The average number of days that receivables remain outstanding before they are collected. Sometimes referred to as Days in Accounts Receivable (DAR).
What is "Gross Days Revenue or Receivables Outstanding" (GDRO)?
A claim payment (remittance) information back to the provider.
What is an "835" file?
AHIMA
What is the acronym for the "American Health Information Management Association"?
A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria.
What is the "Diagnosis Related Group (DRG)"?
Special facility or part of a hospital that provides medically necessary professional services from nurses, physical and occupational therapists, speech pathologists, and audiologists.
What is a "SNF"?
The use of electronic information and telecommunications technologies to support longdistance clinical health care.
What is "Telehealth"?
This is a request for additional documentation on a healthcare claim.
What is an "Additional Development Request" (ADR)?
This is also known as a waiver of liability, is a notice a provider should give a patient before they receive a service.
What is an "Advanced Beneficiary Notification" (ABN)?
An sortable list of accounts receivable with outstanding balances.
What is an "Aged Trial Balance (ATB)"?
Total accounts receivable (A/R) dollars unpaid over 90 days.
What is "Aging Over 90 Days"?
A claims acknowledgement from an inquiry
What is a "277" file?
HIPPA COW
What is the "Health Insurance Portability and Accountability Act Collaborative of Wisconsin".
A 10-digit provider id number
What is the "NPI"?
They make up more than half of all hospitals in the United States, they provide essential access to inpatient, outpatient and emergency services in rural communities
What is a "Rural Hospital"?
Software that reviews medical claims with the goal of stopping incorrect claims or changing claims to fix errors and omissions.
What is a "Claims Scrubber"?
This system allows you to check Medicare beneficiary eligibility data in real-time. Use HETS to prepare accurate Medicare claims, determine beneficiary liability, or check eligibility for specific services.
What is "HIPAA Eligibility Transaction System" (HETS)?
This is a medical billing term to describe the employee for group policies.
What is a "Subscriber"?
Any information in a medical record that can be used to identify an individual
What is "Protected Health Information" (PHI)?
The percentage of claims that are paid on their first submission.
What is the "First Pass Yield"?
An inquiry transaction about a claim.
What is a "276" file?
ACHE
What is the acronym for the "American College of Healthcare Executives"?
A summary of daily patient treatments, charges and payments received.
What is a "Day Sheet"?
A hospital that treats patients for brief but severe episodes of illness.
What is a Short Term Acute Care (STAC)?
A standard method for exchanging electronic healthcare claim and remittance data.
What is a "Data relay protocol (DRP)"?
This is a method where Medicare signals back to a provider that they are going to reject, and therefore, allows the opportunity to fix a claim before final adjudication.
What is "Return to Provider" (RTP)?
Obtaining approval from an insurance company before performing certain medical procedures or services.
What is "Pre-Authorization"?
A statement detailing why a claim was denied by an insurance company.
What is an "Explanation of Denial (EOD)"?
The aggregate money generated from patient services collected from payers, including private insurance, Medicaid, and Medicare.
What is "Net Patient Revenue (NPR)"?
A file that contains information regarding the Patient Information Transaction set.
What is a "275" file?
DHHS
What is the acronym for the "Department of Health and Human Services"?
Standardized code sets that are necessary for Medicare and other health insurance providers to provide healthcare claims that are managed consistently and in an orderly manner.
What is the "HCPCS"?
Software system that provides electronic vs paperbased healthcare patient management. Examples of EHR Systems: Meditech, Epic, Cerner, CPSI, etc.
What is an "EHR/EMR System"?
This is a joint federal and state healthcare program that supports low-income families or individuals.
What is "Medicade"?
This is the process of identifying and confirming a patient’s insurance coverage and benefits before providing services.
What is "Eligibility Verification"?
The requirement that a healthcare service or procedure is reasonable and necessary for the diagnosis or treatment of a medical condition.
What is "Medical Necessity"?
A notice you receive from Medicare explaining the benefits received and not received
What is the "EOB or EOMB"?
Allows healthcare providers to create HIPAA-compliant files requesting eligibility details for a patient.
What is a "271" file?
NGS
What is the acronym for the "National Government Services"?
An editing system created and maintained by CMS to process outpatient facility claims.
What is the "OCE"?
Aggregation of large amounts of healthcare data for use in analysis to gain actionable insights.
What are "Healthcare Analytics"?
A system that automates the processing of Medicare Part A secondary claims.
What is "Accelerated Secondary Billing" (ASB)?
This is a recommendation from a primary care provider for a patient to see a specialist or receive specific medical services.
What is a "Referral"?
An explanation of payments (like claim denials) made by third party payers.
What is "Remittance Advice (RA)"?
A professional paper claim form
What is the "CMS 1500"?
The claim file returned to Epic.
What is a "Claim Reconciliation Database (CRD)"?
HIPPA
What is the acronym for the "Health Insurance Portability and Accountability Act"?
The editing system from CMS that provides decisions on whether a particular service or item is reasonable and necessary and therefore covered by Medicare.
What is the "LCD"?
The ability of different healthcare systems and software products to exchange and use patient information seamlessly.
What is "Interoperability"?
This is a payment system where a health plan or physician is paid a fixed amount of money to cover the cost of a patient’s services for a certain amount of time.
What is a "Capitation System"?
Verifying a patient’s insurance coverage and financial responsibility before providing medical services.
What is "Financial Clearance"?
Maximum units of service (HCPCS/CPT code) a provider will report for a beneficiary on a single date of service.
What are "Medically Unlikely Edits (MUEs)"?
The minimum U.S. government standards for electronic health records, that outlines how patient data should be exchanged between healthcare providers, between providers and insurers, and between providers and patients.
What is "Meaningful Use (MU)"?
The HIPPA electronic transaction standards, replaced 4010.
What is a "5010" file?
EMTALA
What is the acronym for the "Federal law that requires hospital emergency departments medically screen every patient who seeks emergency care regardless of health insurance"?
A unique number that identifies the patients’ medical record.
What is the "MRN"?