The 3Ps & Basics
Any recipient of healthcare services performed by healthcare professionals, also commonly known as a "member" or "subscriber."
Who is a Patient?
The reference document filled out by patients that captures their demographic details, guarantor information, and insurance information
What is the Patient Registration Form (or Face sheet)?
The document sent by a health insurance company to both the provider and patient, explaining whether medical treatments were paid or denied
What is an Explanation of Benefits (EOB)?
These 5-digit numeric codes, developed by the AMA, identify the specific surgeries or medical treatments provided to the patient
What are CPT codes (Procedure Codes)?
The largest federal health insurance program in the U.S. primarily provides coverage for individuals aged 65 and above.
What is Medicare?
An individual or an entity that provides medical services, such as a doctor, hospital, laboratory, or pharmacy
Who is a Provider?
The RCM step where the provider's office cross-checks details by calling the insurance company to confirm the patient's coverage and plan benefits before the visit
What is Eligibility and Benefit Verification (EBV)?
The "act of judging" where the insurance company reviews the claim to determine their financial responsibility and decides to pay, deny, or partially pay
What is Adjudication?
These 3-to-7 character alphanumeric codes are used to identify diseases, disorders, injuries, and symptoms
What are ICD-10 CM codes (Diagnosis Codes)?
A state-run federal insurance policy for people who fall below the poverty line, which almost always acts as the "last payer."
What is Medicaid?
The entity that provides monetary coverage for an individual's current and future medical risks; commonly referred to as the carrier or the third "P."
What is the Payor (or Insurance)?
The clinical stage, where the doctor meets the patient, discusses symptoms, plans the treatment, and records the interaction using a Dictaphone
What is the Encounter?
The team that follows up on unpaid, partially paid, or denied claims to receive maximum reimbursements from insurance companies
What is Accounts Receivable (AR)?
The two-digit code placed on a claim to indicate the setting in which a service was provided, such as "11" for Office or "21" for Inpatient
What is the Place of Service (POS)?
Insurance policies run by the private sector—such as Aetna, Cigna, and Blue Cross Blue Shield—that can be sold individually or as group plans.
What is Commercial Insurance?
A patient is considered "new" if they visit the provider for the first time, or if this exact amount of time has passed since their last visit
What is 36 months (or 3 years)?
The itemized form utilized by healthcare providers to document rendered services serves as the main data source for creating healthcare claims
What is a Superbill (or Charge Sheet)?
temporary claim rejection that does not require an appeal and can be reversed if the provider takes adequate follow-up measures
What is a Soft Denial?
These two-digit additions to a procedure code (like 25, 59, LT, or RT) represent an alteration or specific detail about the treatment provided
What are Modifiers?
In this strict type of managed care plan, visiting a Primary Care Physician (PCP) is mandatory, and referral authorizations are compulsory
What is a Health Maintenance Organization (HMO)?
The specific individual who buys the insurance plan can make changes to the plan and pay the premium
Who is the Subscriber?
The mediator or "gatekeeper" that scrubs electronic claims for syntax errors before they are forwarded to the insurance company.
What is a Clearinghouse?
This improper or excess payment scenario occurs when a patient or insurance pays twice, resulting in a negative balance on the account
What is a Credit Balance?
This red, physical billing form containing 33 blocks is used for non-institutional (physician) claim reimbursements
What is the CMS 1500 form?
This specific Claim Adjustment Reason Code (CARC) is triggered when "The time limit for filing has expired."
What is code CO29?