Health Insurance
Is a promise of compensation for specific potential future losses in exchange for a periodic payment.
What is Insurance?
The person who will be compensated for the cost / loss by an insurer according to the terms specified in the insurance policy.
What is Insured?
Is a comprehensive approach that evaluates, improves and manages all components like obtaining information on patient’s visit to doctor/hospital, ensuring patient safety, creating a simplified, integrated workflow designed to optimize and expedite reimbursement.
What is RCM?
It is Also known as the Kennedy-Kassebaum Act.
Is a bill for health care services rendered that is given to a payer for payment.
What is a Claim?
Is a contract between a policyholder and an insurance carrier or government program to reimburse the policy holder for all or a portion of the cost of medically necessary treatment or preventive care rendered by health care professionals.
What is Healthcare/Health Insurance?
Any facility or personnel that provide medical and health care services.
What is Provider?
A process where if a claim is partly paid or denied, the system changes the claim status to self-pay (payment by the patient) or have the claim billed to a secondary payer(any other insurance enrolled by the patient)
What is Payment Posting Process?
Is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.
What is PHI/Protected Health Information?
The part of the life cycle where after the service has been rendered charges are generated. The charge becomes a claim, and the claim becomes part of a file.
What is Claim Generation?
Provides health insurance programs to specific groups, such as elderly and people who qualify because their income is below the federal poverty level.
What is US Government Insurance?
The contractual agreement between the insurer and the insured that lays out the benefits, exclusions and the limitations of the insurance coverage.
What is Policy?
A process where collectors research why a claim has been denied, partially paid, or when response from payer is not received.
Collections Process
The goal of this rule is to ensure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being.
What is Privacy Rule?
The part of the life cycle where provider submits the claim, whether they are considered In-Network or Out-of-Network with the patient’s health plan. The claim can be submitted either in paper format or electronic data interchange format.
What is Claim Submission?
Is a federal health insurance program for people who are 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).
What is Medicare?
The percentage of costs of a covered health care service the patient is billed for (20%, for example) after the deductible has been met.
What is Coinsurance?
These are the 3 main phases of RCM.
What is Front, Middle and Back office?
This entity that is required to follow HIPAA are essentially the middleman between the healthcare providers and the insurance payers who checks the medical claims for errors.
What is a Healthcare Clearing House?
The part of the life cycle where we determine the patient's eligibility, verify billed dates of service and calculate the payment to be made.
What is Adjudication?
Simply refers to any health insurance coverage that is not offered by a state or federal government.
What is Private Health Insurance?
A statement sent to the provider/patient by the health plan that lists the services provided, amounts billed, and payments made.
What is Explanation of Benefits?
What is Deductible, Copay and Coinsurance?
Give atleast 2 information covered by HIPAA.
What is:
- Patient Personal Information
- Patient Medical Records
- Patient Payment/Credit Card Information
- Patient Insurance Information
The last part of the life cycle which is vital to the financial reporting process.
What is Claim Reporting?