The Electronic Claim
What does ASP stand for?
Application Service Provider - In medicine is a company that hosts and manages healthcare software.
What is an EFT?
Electronic Funds Transfer - a digital movement of money from one bank account to another using computer systems and online networks. Common types: direct deposit, wire transfers, and card payments.
What should you do with a denied claim?
1. Correct It
2. Appeal It
3. Collect from the Patient
What is payment posting?
Logging money received from insurance companies and matching it to the right patient accounts
What does A/R stand for?
Accounts Receivable - (AR) is the money customers owe a business for goods or services delivered.
What does EDI stand for?
Electronic Data Interchange - in medicine is the computer to computer exchange of secure, standardized business and clinical data between healthcare providers and insurance payers.
What are some benefits for EFT (Electronic Funds Transfers)?
1. Speed
2. Convenience
3. Security
What does RCM stand for?
Revenue Cycle Management - in medical billing is a 8-Step Financial process covering patient registration, medical coding, and final payment collection.
What is denial management?
Fixing and appealing claims that were rejected or underpaid by the insurance.
List an Adjustment that a doctor can approve for a patient that has a balance.
2. Senior Discount Adjustment
3. Billing Error Adjustment
4. Cash Pay Adjustment
The Digital Submission, Tracking, and Processing of Insurance Claims Through Online Platforms Instead of Paperwork.
What is E-Claims?
What is an ERA?
Electronic Remittance Advice - a digital version of a paper Explanation of Benefits (EOB) that explains how a health plan processed and paid a medical claim.
What information should you collect during PATIENT REGISTRATION?
1. Personal Details
2. Contact Info
3. Insurance Data
What is patient billing?
Sending statements to patients for any leftover balance they owe after insurance pays.
Why are Prior Authorizations so important?
A prior authorization is an approval your health insurance company requires before they will cover a specific medical service, procedure, or prescription drug. Your doctor's office or healthcare provider handles the submission process by sending medical records and proof of medical necessity directly to your insurance company.
What are some advantages of the Electronic Claim Submission?
1. Faster Payments
2. Reduces Costly Errors
3. Lowers Admin Overhead
4. Fewer Rejections
5. Improved Cash Flow
What is a Claims Transmission Summary Report?
Claims Transmission Summary Reports generate how many total claims were originally received by the payer and how many were automatically rejected.
What information do you need confirm during insurance verification?
1. Active Coverage
2. Plan Limits
3. Copays
4. Required Prior Authorizations
Resolved or paid within 7 to 14 days (or up to 30 calendar days for clean claims under updated prompt-pay regulations)
Explain the Prior Authorization Process.
Check requirements, Gather details, Fill out the form, Submit the request, Track the status.
What does NPI stand for?
National Provider Identification - A unique 10-digit numeric number assigned to health care providers by the Centers for Medicare & Medicaid Services (CMS)
What are some problems that can occur with Electronic Claims?
1. Incorrect Patient Info
2. Missing Provider Data
3. Coding Mistakes
4. Internet Connection Fails
What is important: clinical documentation required for the RCM process?
1. Doctor Notes
2. Diagnosis
3. Treatments
What is NOT A BILL, but shows what transpired or what may be owed, but is not a direct request for payment?
List Items that Require Prior Authorizations.
Specialty Drugs
Major Procedures/Planned Surgeries
Advanced Imaging/MRIs/CT Scans
Medical Equipment