Insurance
The insurance filing order rule that states "The policy of whichever parent's birthday comes first in the calendar year, regardless of the year of birth is primary"
What is the Birthday Rule?
Full Legal Name, Date of Birth, and Social Security Number are?
What are Patient Identifiers?
The person who contracts with the insurance company for healthcare coverage.
What is Policyholder, Subscriber, and Sponsor?
The form Medicare Beneficiaries must sign when authorization is not obtained from the insurance carrier for the ordered procedure, or diagnostic testing and the carrier may not pay for the service.
What is Advanced Beneficiary Notice of Noncoverage (ABN)?
The entire life of a patient account from the creation to final payment and zero balance.
What is Revenue Cycle?
The insurance filing order rules that states "The individual's own policy is primary - the patient is always primary for him/herself"
What is the Insured Dependent Rule?
The form informs hospitalized observation beneficiaries that Medicare may not pay for prescriptions and certain testing and must be signed within the first 36 hours of their outpatient admission.
What is Medicare Outpatient Observation Notice (MOON)
A fixed amount the patient pays for covered healthcare services. The amount varies by the type of services covered.
What is a Copayment?
The amount owed by the patient for healthcare services before health insurance begins to pay.
What is a deductible?
The person who is responsible for any outstanding balance as a self-pay patient or after a third-party payment has been received.
What is the guarantor?
The term used by Medicare when it is NOT the primary payer.
What is Medicare Secondary Payer?
The form informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights and must be signed within the first 48 hours of their admission.
What is Important Message from Medicare (IMM)
The Guarantor account is used when a patient has been in an auto accident.
What is a Third-Party Liability Guarantor?
The percentage of the allowed amount for the healthcare services that is the patient's responsibility.
What is Co-Insurance?
The department in which Demographic and insurance information is collected and entered in the system, verification of eligibility and benefits, have financial conversations, etc.
What is Patient Access?
The process in healthcare where a healthcare provider must obtain approval from a patient's health insurance plan before prescribing certain treatments, medications, or services.
What is Prior Authorization?
The process of ensuring patients understand their financial obligations before receiving services, verifying insurance coverage, and estimating out-of-pocket costs to prevent unexpected billing and streamline billing.
What is Financial Clearance?
The code that identifies a significant event relating to a claim which may affect paper processing. These codes are claim related occurrences that relate to a specific date.
What are Occurrence Codes?
A company that manages a plan or another entity by processing claims or managing authorizations.
What is a Third Party Administrator (TPA)?
When insurance puts a time limit on claim submission.
What is timely filing?
The type of plan known as Part C, is a private health insurance alternative to traditional Medicare, offering the same coverage as Part A and B, and often including Part D and additional benefits.
What is a Medicare Advantage Plan?
This key approach in healthcare aims to improve patient safety, enhance quality of care, and promote efficiency by establishing clear, consistent, and evidence-based procedures for all team members.
What is Standard Work?
The process of determining what health benefits are available to a patient and the appropriate order of assigning them.
What is Coordination of Benefits?
The phrase used when a person is 65 or older AND working or has a working spouse.
What is Working Aged?
The form a Billing Department utilizes to submit charges for a patient's encounter to a payer.
What is a Claim?