Chapter 7-8
Entity sending claim to payer
What is billing provider?
A managed care participant needing emergency treatment by an outside network area
What is urgently needed care?
Applicants have low incomes and few resources
What is categorically needy?
Dept of Defense's health insurance plan for military personnel and their family
What is Tricare?
Authorization sought by payer for elective hospital based services and outpatient surgery
What is Precertification?
In Medicare, highest fee non participating physicians may charge for a particular service (cannot be more than 115% of medicare fee schedule)
What is limiting charge?
This will restrict you to a specific provider
What is restricted status?
Program funded by worker's payroll deductions and matching employer contributions that provides compensation for lost wages
What is Social Security Disability Insurance(SSDI)?
Payer's initial processing of a claim screens for these
What are basic errors in claim data or missing info?
Insurance plan requiring large amount of money to be paid before benefits begin.
What is a higher deductible plan?
Medicare pays 80% of allowed services
What is Medicare Part B Fee for service?
These applicants have high medical bills and incomes that exceed state limits
What is medically needy?
The max percentage of allowed charges that non participating Tricare can bill.
What is 115%
System that shows which patients are overdue on their bills and groups them into distinct categories for efficient collection efforts
What is patient aging report?
All major types of health plans
What does BCBS Association members offer?
Contractor who handle claims and related functions and conducts the Medicare Medical Review.
What is The MAC?
What is TANF?
Documents filed with ins carrier when there is a substantial change in patient's condition that affects the status of occupational illness
What is progress report?
Process that assigns patient accounts to specific time of month and standardizes times when statements will be mailed and payments will be due
What is Cycle Billing
Payments arrive faster than under other types of plans
What is Consumer driven health plans?
What is Medigap?
This program requires individuals to use their own financial resources to pay for portion of their income on their healthcare
What is Spend down?
This term is when the patient is responsible for the amount of the provider charges
What is Cost Share
Patient eligibility, duplicate claims, non covered services
What are automated edit examples?