Insurance Terminology
Amount patient must pay before insurance coverage begins to pay the provider.
This was established in order to set national standards for: Electronic health care transactions, code sets, unique health identifiers, Security, the privacy of protected health information (PHI)
What is HIPAA?
This RA Code provides an additional explanation for a claim adjustment reason code.
What is the RARC?
EOB
What is Explanation of Benefits?
Prior authorization of services is one method of veryifing that a requested service is __________.
What is medically necessary?
Number assigned by insurance company to identify the group under which a patient is insured.
What is the Group Number?
A _________ ________ subject to HIPAA is an individual or facility that creates patients’ physical or mental health information and transmits PHI in any type of electronic form
What is a covered entity?
This RA Code tells why a claim or charge was paid differently than it was billed.
What is the CARC?
ICN
What is Internal Control Number?
When an insurance plan does not pay for treatment, an _______ is the process of objecting this decision.
What is an appeal?
This is a medical record in digital format of a patient’s hospital or provider treatment. This format is designed to be shared/ exported throughout the nation.
What is an EHR (Electronic Health Record)?
Established a set of standards to protect PHI that is electronically held or transmitted.
What is the Security Rule?
If you receive a denial for "other payor primary", this means that member hasn't updated their insurance information. Insurance payors may request from the patient that a Other Health Insurance form be filled out and sent back within a specific time frame. This is to determine what?
What is COB?
SAD
Self-Administration Drugs
CO96
What is non-covered charges?
Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.
What is Prior-Authorization?
_________ may be disclosed to the patient, facility-owned treatment entities including consultants and other providers, and payment and health care operations such as billing, business planning and quality review.
What is PHI (Protected Health Information)?
Claim is that has errors sent back to the provider.
What is a rejected claim?
DX
What is diagnosis?
CO50
What is payer deemed not medically necessary?
Once the claim is sent to the insurance company, the insurance company processes the claim, this process is called ___________.
What is the adjudication process?
Any _________ ________ who deal with personal information must specify the contract with the health care organization how they will safeguard PHI.
What is business associate?
Claim with an ICN returned back to the provider is known as a ____________.
What is a denied claim?
ABN
What is Advanced Beneficiary Notice?
CO29
What is the time limit for filing has expired?