Front-End Fundamentals
This process confirms a patient's active insurance coverage before services are rendered.
What is eligibility verification?
A claim submitted with all required information and no errors.
What is a clean claim?
The amount a patient must pay before insurance begins paying covered services.
What is a deductible?
The first document reviewed when researching a denial.
What is the remittance advice (RA) or EOB?
Contacting the payer to obtain claim status is a key part of this process.
What is insurance follow-up?
This should be obtained before services that require payer approval.
What is prior authorization?
Missing modifiers, diagnosis codes, and NPIs can cause these.
What are claim rejections?
A fixed amount a patient pays for a covered service.
What is a copay?
This denial occurs when a claim is filed too late.
What is a timely filing denial?
Claims with no payer response after submission are often placed in this status.
What is pending?
Collecting this at registration helps prevent claim rejections.
What is accurate demographic information?
This review process occurs before a claim is sent to the payer.
What is claim scrubbing?
The percentage of costs shared by the member after the deductible is met.
What is coinsurance?
This denial occurs when approval was required but not obtained.
What is an authorization denial?
Representatives should document every payer conversation in these.
What are account notes?
Patients with multiple insurance plans require this process.
What is coordination of benefits (COB)?
Claims are generally sent to this entity before reaching the payer.
What is a clearinghouse?
The patient's financial responsibility after insurance processes the claim.
What is patient liability?
This documentation is often requested to support an appeal.
What are medical records?
This number is often obtained when speaking to a payer representative.
What is a call reference number?
This document is often copied during registration to verify coverage.
What is the insurance card?
The goal of claim editing is to reduce these.
What are denials?
The process of seeking payment from patients after insurance adjudication.
What is patient collections?
The goal of an appeal is to overturn this.
What is a denial?
The purpose of follow-up is to secure this.
What is reimbursement?