Registration & Eligibility
This information must be verified at every visit to avoid claim rejections.
What is insurance eligibility?
The numeric or alphanumeric representation of a diagnosis.
What is an ICD‑10 code?
A request sent to the payer asking for reimbursement.
What is a claim?
When a payer refuses to reimburse a claim.
What is a denial?
The full process from patient scheduling to payment posting.
What is the Revenue Cycle?
This refers to the patient’s personal information, such as address and DOB.
What is demographics?
Providers must complete this to support coding and billing.
What is medical documentation?
Errors in claims are flagged as these before submission.
What are edits?
The process of challenging a denial to get it overturned.
What is an appeal?
This step occurs when a provider asks the payer to review a previously denied claim without submitting a formal appeal, often used when additional information or clarification can resolve the issue.
What is a reconsideration?
The patient payment collected before a service based on their insurance plan.
What is a copay?
These two‑digit additions help give extra detail to CPT codes.
What are modifiers?
The amount owed by the patient after insurance pays their portion.
What is the patient balance?
This type of denial occurs when the patient’s coverage lapsed.
This type of denial occurs when the patient’s coverage lapsed.
This document lists all services and charges for the patient.
IB
The process of confirming if prior approval is needed for a service.
What is pre‑authorization?
This type of note describes the patient encounter narrative.
What is the progress note?
This describes the maximum number of days allowed to submit a claim.
What is the timely filing limit?
Payers sometimes take back previously paid money in this process.
What is recoupment?
This term describes the percentage of the allowed amount that a patient must pay after the deductible is met, often resulting in shared cost responsibility between the patient and the insurance plan.
What is coinsurance?
Denial occurs when the service level billed does not match what was authorized
Level-of-care denial
This principle requires that medical record documentation supports the intensity of the service billed, including history, exam, and medical decision‑making.
What is Medical Necessity?
A change to the original billed amount, usually due to payer rules or contracts.
What is an adjustment?
This denial occurs when a claim is rejected because the payer has already processed another claim for the same patient, same date of service, and same procedure—flagging it as a suspected duplicate.
What is a duplicate claim denial?
A payer explanation sent with details about how a claim was processed.
What is an EOB or remittance advice?