Definitions
Provides treatment and medical care to individuals or a community
Healthcare
During this step the payer is called to check if the patient's policy is active for the date the patient is planning to visit the provider
Verification
What does EOB stand for?
Explanation of Benefits
When the allowed amount for covered services is denied by the Payer
Denial
Who takes care of Password resets for the patient?
ProHealth
Visits with patients who do not transfer care and are seen by another family physician in the original group within the 3 year time frame.
Established Visit
Anything that has been partially paid or denied
What does the abbreviation SOP stand for?
Standard Operating Procedures
Conditions excluded from coverage because they had signs and symptoms or were diagnosed prior to the policy start date.
Pre - Existing Conditions
There are a few cases where scheduling an appointment is NOT mandatory.. what are they?
Urgent Care Centers, ER, Laboratory, Simple X Rays
States that insurance/payer can make payments directly to the providers office rather than the patient
Assignment of Benefits (AOB)
When the patient and the provider meet
Encounter
What does the abbreviation EHR stand for?
Electronic Health Record
What is the electronic form of an EOB called?
Electronic Remittance Advice (ERA)
What is the "Goal of Billing"?
submit "clean" claims and get reimbursed at first submission
Provider records conversations with patients on a device called
Dictaphore
These universal codes are used to see the billing process
Coding & Charge Capture
What does the HIPAA abbreviation stand for?
Health Insurance Portability and Accountability
Percentage of costs after the patient pays the deductible.
Co - Insurance
When it comes to QA Scoring, what percentage is a critical and non-critical error worth?
Critical: 100%; Non-Critical: 5%
When the claim reaches the payer and they decide whether to pay or deny the claim, based on their policies and procedures
Adjudication
Entered in the EHR by medical assistants and the provider seeing the patient before, during, and after the encounter
What is saved?
Documentation; Services provided by the provider, Procedure taken place, and Personal information
What does the CPT and HCPCS abbreviation stand for?
T/F: Billed Amount minus Allowed Amount equals Patient Responsibility
False: Billed Amount - Allowed Amount = contractual adjustment; Allowed Amount - Paid Amount = Patient Responsibility
How long is the ROI valid for and where can the patient submit this form?
1 year; Facility