Intro to RCM
Abbreviated as RCM.
What is Revenue Cycle Management?
The first and last step in the billing cycle.
What is Patient checks in and visit capture completed?
The definition of Medical Coding.
What is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes?
A bill for health care services rendered that is given to a payer for payment.
What is a claim?
A form that is sent to both patients and provider offices to provide the summary of reimbursement for each claim. The procedures and services listed were processed with payment being sent to the provider.
What is an EOB (Explanation of Benefits)?
This is when it's best to obtain a prior authorization.
What is before services are rendered?
What is at the Front End?
Define Member Deductible.
The amount paid by the patient for services before the insurance plan starts to pay
Name at least 3 medical code types you should be aware of when reviewing a claim for edits.
What is CPT-4, HCPCS, CM, ICD-10 CM, ICD-10 PCS, Diagnosis Codes, Modifiers, Procedure Codes, Revenue Codes?
Way to file a claim.
What is electronically (EDI), mail, fax, email, web portals?
A financial document produced from a commercial insurance carrier, claim administrator, medical group or government funded insurance program that is provided to a medical service provider.
What is an Electronic Remittance Advice(ERA) is an electronic version of an EOB.
The definition of Revenue Cycle.
What is All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue?
HIPAA
(100 bonus points for the year it was established)
Health Insurance Portability and Accountability Act
(1996)
Codes that are used to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, and injuries.
What is diagnosis codes?
The purpose of a claims clearinghouse.
(100 bonus points if you can add what clearing house we use for AHN)
What is Receive the claim from the provider and transfer it to the payer?
(Availity/RealMed)
RARC and CARC
Remittance Advice Remark Codes (RARC)
Claim Adjustment Reason Code.
The stage of the revenue cycle that does documentation, charge capture, and coding,
What is the Middle?
Explain the below terms
CMS-1500 Claim Form
CPT
ICD-10-CM
What is...
CMS-1500 Claim Form: is the standard claim form used by a non-institutional provider or supplier to bill an insurance company (HCFA)
CPT: The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set accurately describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The CPT code tells the payer WHAT service the provider rendered. CPT codes are 5 digit codes and are also referred to as procedure codes.
ICD-10-CM: (Diagnosis Codes)International Classification of Diseases – Created by the World Health Organization to classify disease, this set of codes is used to provide the diagnosis or the WHY for the service provided.
Codes that are used to identify specific surgical, medical or diagnostic interventions.
What is Procedure Codes?
What is CPT Codes?
The patient deductible.
What is The amount paid for services rendered or The amount paid out of pocket for services covered by the plan?
Known as an itemized bill.
EOB
Name 3 common rejection reasons.
The definition of co payment and coinsurance.
Copayment A fixed amount a member pays to the provider for a covered health care service, usually at the time the services is received
Coinsurance The member’s share of the costs of a covered health care service, calculated as a percent of the allowed amount for that service
Medical codes that give a description of where services were performed – i.e. emergency room or physician’s office
Claim status types.
What is pending, denied, or paid?
835
What is ERA, RA ?