Hospital Terms
Evaluation and Management
What does the acronym E/M stand for?
Current Procedural Terminology
What does CPT stand for?
This is a system that contains a digital version of a patient’s paper chart.
Examples: Meditech, Epic, Cerner, CPSI, etc.
What is an "EHR or EMR"?
The United States federal government health insurance program for Americans who are 65 years of age or older
What is "Medicare"?
This acronym refers to point-of-service
What is "POS"?
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 claims which have no defects or special circumstances and have a timely payment as a subset of all claims
What is the "Clean Claim or Validation Rate" (CCR)?
A file with claims sent to a payer, Institutional, services in a facility
What is the "837I" file?
This acronym describes "Long-term acute care"
What is "LTAC"?
99212–99215
Which CPT code range covers office or other outpatient visits for an established patient?
This is a shared instance of a larger EMR (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"?
King in Healthcare
What is a cash?
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 compares the total dollar amount of claims that have been rejected by payers within a given time period to the total dollar amount of claims submitted within the same time period
What is the "Denial Rate"?
A file with claims sent to a payer, Professional, a professional's time
What is the "837P" file?
ABN
What is Advanced Beneficiary Notice?
99204
Which CPT code is used for a new patient office visit with moderate complexity?
This is a subsystem of a hospital information system used for storing financial data, calculating healthcare costs, and providing billing information.
What is a "Patient Accounting System" (PAS)?
These are costs that are a patient's responsibility for hospitalization between day 61-90 days
What are "Medicare Coinsurance Days"?
A responsible party and/or insured party who is not necessarily the patient.
Who is a "Guarantor"?
Hospital bills that have completed service but have not been billed to insurance yet
What is "Discharged, Not Final Billed" (DNFB)?
Outstanding charges that are the patient's responsibility that have not been successfully collected which are eventually written off and sent to a collection agency
What is "Bad Debt"?
An transaction set and 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?
This program is intended to increase access to primary care in rural communities, to receive certification, they must be located in rural, undeserved areas.
What is a "Rural Health Clinic" (RHC)?
Service included in the payment for another service (bundled)
What is a CO-97 denial
Prior to submitting claims, the organization/technology scrubs a claim and checks for errors then electronically transmits claim information that is compliant with HIPAA standards.
What is a "Clearinghouse"?
Medicare Timely Filing
What is 365 days?
This is sometimes required by a patient’s insurance company to determine medical necessity, but does not guarantee benefits will be paid
What is "Pre-Certification"?
Tracking of dollars not submitted to payers; when 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"?
A calculation that compares the Total Outstanding A/R to Average Daily Revenue
What is "Gross Days Revenue or Receivables Outstanding" (GDRO)?
A payment file sent back to the provider
What is an "835" file?
This acronym describes a "Skilled Nursing Facility"
What is a "SNF"?
90–180 days from the date of service
What is the typical timely filing limit for commercial payers?
The use of electronic information and telecommunications technologies to support long-distance clinical health care
What is "Telehealth"?
This term refers to a request for additional documentation on the claim
What is an "Additional Development Request" (ADR)?
This is also known as a waiver of liability, and is a notice a provider should give you before your receive a service.
What is an "Advanced Beneficiary Notification" (ABN)?
An alphabetical list of accounts receivable with outstanding balances
What is an "Aged Trial Balance"?
A calculation that compares Total A/R Aged over 90 days to Total Accounts Receivable
What is "Aging Over 90 Days"?
A claims acknowledgement from an inquiry
What is a "277" file?
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"?
Resubmitting before the original claim has finalized or using the same control number
What’s a common cause of duplicate claim denials?
This software aims to rid medical claims of errors and omissions
What is a "Claims Scrubber"?
The fixed amount patients pay each time they receive services
What is Co-pay?
This is a medical billing term to describe the employee who is a part of a group policy
What is a "Subscriber"?
RAC
What is Recovery Audit Contractor?
An institutional paper claim form
What is the "UB04"?
An inquiry transaction about a claim
What is a "276" file?
The prices that hospitals get paid from Medicare for certain services. CAHs receive different reimbursement given their designation otherwise.
What is the "Prospective Payment System" (PPS)?
Checks claims for errors before submission
What does “claim scrubber” software do?
SlicerDicer
What tool in Epic can help analyze claim trends and denials?
This state of the claim cycle involves comparing the claim to payor edits and the patient's health plan benefits
What is adjudication?
A confirmation of coverage
What is "Eligibility"?
TOB
What is type of bill?
Explanation of Benefits
What is an EOB
A file that contains information regarding the Patient Information Transaction set
What is a "275" file?
Bad Debt Agency
What is NBF (National Business Factors)
Claim rejects for invalid or missing POS code
What is a common edit for missing place of service?
Recording payments received from insurance companies and patients to individual patient accounts
What is payment posting?
This is a healthcare program that supports low-income families or individuals
What is "Medicaid"?
RTE
What is Real-Time Eligibility?
Discharged, Not Final Billed
What does "DNFB" stand for?
A notice you receive from Medicare explaining the benefits received and not received
What is the "EOB or EOMB"?
HIPPA-compliant files requesting eligibility details for a patient
What is a "271" file?
EMTALA
Claim Adjustment Reason Code
What does “CARC” stand for in denials terminology?
Secure online patient portal
What is MyChart?
Four stages of the insurance claim cycle, in order
What is submission, processing, adjudication, and payment?
Health Plan requirement of review and approval of procedure prior to services
What is Prior Authorization?
131 Type of Bill
What is Outpatient Hospital Services?
A professional paper claim form
What is the "CMS 1500"?
A file returned to Epic
What is a "CRD" file?
CMS
What is Centers for Medicare and Medicaid Services?
This code gives the billed service a different meaning or adds additional information
What is a modifier?
Three digit code linked to every charge
What is a revenue code?
An overpayment or adjustment performed on an account causing the balance to fall below zero
What is a credit balance?
Bank account numbers, social security number, credit card info, tax info, date of birth
What is PHI?
What is the impact of prior payer(s) adjudication including payments and/or adjustments
Carson Tahoe's CFO
Katie Kucera
Benefit enrollment data
What is an 834?