Scheduling
Scheduling method also referred to as streaming. Set appointment times.
time-specified scheduling
Medically necessary within 24 hours.
Urgent appointment
Commercial and government health plans
Type of payer
A report that lists outstanding balances that have not been paid by either the patient or the insurance payer.
aging reports
An order from a provider for a patient to see a specialist or to obtain specific medical services.
referral
Grouping similar patient conditions at specific times.
block scheduling
Received services from the same provider or same group (and the same specialty) within three years. Includes known condition.
Established / follow-up
Meeting the stipulated requirements to participate in the health care plan.
eligibility
Sometimes required by a payer to determine medical necessity for the proposed services.
preauthorization
The length of time from the date of service in which a health care organization may submit a claim to the third-party payer. Timely filing varies by payer and may range from 90 days to one year from the date of service. Claims that exceed timely filing are not payable.
timely filing
Unscheduled walk-ins; occurs during open office hours and in the order of their arrival.
open-booking
Has not received services from the provider or same group (and the same specialty) within three years.
New patient
CPT, HCPCS, ICD-10-CM
Types of codes
A reimbursement model intended to improve the traditional fee-for-service method by changing the focus to value-based care rather than volume-based care.
pay-for-performance (P4P)
Rewards the provider with incentive payments for meeting defined program performance standards.
value-based care model
A type of scheduling in which two or more patients are scheduled within the same time slot.
double-booking
Through review of body systems including preventative care and screenings.
Complete annual physical exam
Does not agree to a payer’s allowed amount and is not required by contract to do so. This may be referred to as out-of-network for managed care payers.
non-participating (non-PAR) provider
An organization that accepts the claims data from a health care provider, performs edits comparable to payer edits, and submits clean claims to the third-party payer.
clearinghouse
A series of administrative functions that are required to capture and collect payment for services provided by a health care organization.
revenue cycle
Schedule two or three patients during a designated hourly time period (last 30 min of the hour, patients seen in order of arrival).
wave scheduling
New or established patient for a specified complaint at highest coding level, multiple complaints, injuries, or worsening chronic condition
Comprehensive visit
Agrees to accept the payer’s allowed amount (regardless of the billed amount). This may be referred to as in-network for managed care payers.
participating (PAR) provider
A response from the payer of claims payment and an explanation of patient responsibility amounts and any adjustments made to the billed amount by the payer.
remittance advice
A managed care method of monthly payments to the provider based on the number of enrolled patients, regardless of how many encounters a patient may have during the month.
capitation