VOB 101
This is a specific amount that the patient must pay for healthcare services before the health insurance plan begins to cover costs.
Deductible
What is the required indicator for a corrected claim?
Frequency Code 7
What do you need before you can post a patient payment?
Receipt
These explain why a service was performed
(ICD-10) codes
What is the meaning of HIPAA?
The Health Insurance Portability and Accountability Act.
This refers to a policy where payers reimburse the full rate for the highest allowable procedure performed during a single encounter.
Subsequent procedures are reimbursed at a reduced rate, typically following a pre-negotiated percentage.
MPR - Multiple Procedure Discount
What are 4 parts of the Medicare and its description?
A - Hospital Insurance - Inpatient, hospice, skilled nursing
B - Medical Insurance - Doctors, outpatient, preventive
C - Medicare Advantage - A + B + extras (private plans)
D - Drug Coverage - Prescription medication
What transaction code is used when correcting a prior TOB adjustment that was posted in error due to a change/update to the linked payer contract?
W/O Contractual – W/O Contract Updated After TOB Correction.
What does denial code CO-29 indicate?
Timely filing limit exceeded
What do we call for claim free of errors that gets processed promptly without delay or rejections.
Clean Claim
This individual or group is responsible for the initiation of prior Authorization requests.
Rendering Physician
Exparel is typically used in total joint cases for pain management. A 20 mL vial would be billed at how many units?
266 units
If something was added to the DDL this month but it was in the bank last month it will be on the DDL as what type of entry?
Reconcile
What do we call the financial responsibility that is transferred to the patient after insurance processes the claim?
Patient Responsibility
What does the CO-45 remark code indicate?
Charge exceeds fee schedule, Contractual Adjustments
This plan requires use of in-network providers and designate a primary care physician (PCP). This ensures coordinated care but limits options to a specific network of doctors and facilities.
Referrals are needed for specialist visits, and coverage is limited for OON services.
HMO (Health Maintenance Organization)
What percentage reduction does sequestration apply to Medicare?
2% reduction
Other then Payment Packet and Daily Reconciliation, what tool can we check to confirm the payment has been received?
DDL
This AR process involves comparing the payer’s payment on the EOB to the contracted rate, identifying any variance where the paid amount is less than expected.
Underpayments
What year was USPI founded?
USPI was founded last 1998 with a promise to deliver high-quality, lower-cost solutions in our communities.
A patient has an unmet deductible of $500, an in-network coinsurance rate of 20%, and an out-of-pocket maximum of $5,000. If the total case allowable is $3,000, what is the patient's estimated financial responsibility?
$1,000
In COB, which plan pays first for a dependent child when both parents have coverage?
Birthday Rule
What should you do if the insurance paid the full allowable amount, but there is still a patient payment in the ledger?
Add a “Patient Refund Needed” transaction code and create a refund packet.
How to Handle Pre-auth denial?
This AR process begins by checking if retro authorization is allowed by the payer, and if not, moves forward with submitting a formal appeal for a denied preauthorization.
When is the USPI Manila launch?
September 01, 2025