electronic remittance advice (ERA)
The remittance advice submitted to the provider electronically is called this.
Any procedure or service reported on the claim that is not included on the master benefit. This will result in denial (rejection) of the claim.
Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization.
Routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated.
Organized by month and insurance company and have been submitted to the carrier, but processing is not complete.
Filed according to year and insurance company and include those for which all processing, including appeals, has been completed.
Organized by year and are generated for providers who do not accept assignments; the file includes all unassiged claims for which the provider is not obligated to perform any follow-up work.
Any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage.
Termination of coverage
The payer has denied this claim because the patient is no longer covered by the insurance policy.
Out-of-network provider used
The payer has denied payment because treatment was provided outside the provider network.
value-added network (VAN)
A clearinghouse that involves value-added vendors, such as banks, in the processing of claims.
Electronic Healthcare Network Accreditation Commission (EHNAC)
The accreditation agency to check with to see if a clearinghouse is accredited.
electronic flat file format
A series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.
Includes all private-sector health plans (excluding certain small self-administered health plans); managed care organizations; ERISA-covered health benefit plans; government health plans; all health care clearinghouses; and all health care providers that choose to submit or receive these transactions electronically.
Contains all required data elements needed to process and pay the claim (e.g., valid diagnosis and procedure/service codes, modifiers, and so on.
A set of supporting documentation or information associated with a health care claim or patient encounter.
coordination of benefits (COB)
A provision in group health insurance policies intended to keep multiple insurers from paying benefits covered by other policies; it also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.
Involves sorting claims upon submission to collect and verify information about the patient and the provider.
When the claim is compared to payer edits and the patients health plan benefits to make certain verifications.
The maximum amount the payer will allow for each procedure or service, according to the patient's policy.
The total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits.
The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
The provider agrees to accept what the insurance company allows or approves as payment in full for the claim.
accounts receivable management
Assists providers in the collection of appropriate reimbursement for services rendered.
participating provider (PAR)
Contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed.
nonparticipating provider (nonPAR)
Also, out-of-network provider, does not contract with the insurance plan, and patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses.
States the policholder whose birth month and day occurs earlier in the calendar year holds the primary policy for dependent children.
The financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter.
A permanent record of all financial transactions between the patient and the practice.
manual daily accounts receivable journal
Also known as a day sheet, this is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific day.
The transmission of claims data (electronically or manually) to payers or clearinghouses for processing.
A public or private entity that processes or facilitates the processing of nonstandard data elements (e.g., paper claim) into standard data elements (e.g., electronic claim).