Cats
Routine health care that includes screenings and check-ups to prevent illnesses, disease or other health issues
Preventative Services
The timeframe a provider/hospital has to submit a claim for services provided for payment to a payor
Timely Filing
Coinsurance is defined as
A percentage of a medical charge that a patient pays that typically applies after a patient’s deductible has been met
Non-government Insurance is known as
Commercial health insurance
Billing claim form for the professional charges
CMS-HCFA-1500
The process by which a patient or provider attempts to persuade an insurance payer to pay more of a denied medical claim
Appeal
A Facility/Provider who has a contract with the patient’s health insurer or plan to pay for services
In-network provider
Set of five-digit codes for billing and authorization of evaluation and management services broken down into groupings
Current Procedural Terminology Codes (CPT)
The insurance company with the first responsibility for the payment of a claim
Primary insurance company
What the payer says they will consider out of the submitted line item charges (total charges)
Allowed Amount
Out-of-pocket maximum/limit is the most money that a patient could have to pay for covered services in a plan year. What item listed below is not included in calculating this limit?
Monthly Premiums Paid
The number assigned by the health insurance company when they accept a claim in their system for review and payment
Document Control Number (DCN)
Number assigned to identify each episode of care (Date of Service)
Account number/Visit Number/Encounter Number
State Government Plan/Payer of Last Resort
Medicaid
In-patient hospital coverage under the Medicare program
Medicare Part A
Agreement that determines which insurer has primary responsibility for payment an which has secondary responsibility
Coordination of Benefits (COB)
The insurance company responsible for processing the claim after the primary insurance determines what it will pay
Secondary Insurance Company
The electronic payer notification of how the claim was processed and/or paid
Electronic Remittance Advice (ERA)
Process of determining if a patient’s insurance plan is active for scheduled date of the medical service/procedure
Eligibility
Billing a patient for more than the payer’s allowed amount of the charges
Balance Billing
What Remark code is used when a CPT/HCPCS code denies for no authorization/ pre-certification
CO 197
. When does the Medicare enrollment process begin?
3 months prior to turning 65
The timely filing guidelines for Medicare is 12 months from the date of service/dc date
True
Payment methodology for inpatient hospital claims based on medical severity of illness
Diagnosis-related groups (DRG)
Two different levels of coding methodology utilized in billing services and/or supplies, drugs and equipment. Level I is identical to CPT codes. Level II is used to identify drugs, supplies and equipment used to treat the patient (Technical Charges). It is used primarily by Medicare and Medicaid, but can also be used by other insurance providers