Health Insurance - Ch 4 (Processing an Insurance Claim)

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Green & Rowell - 10th Edition

electronic remittance advice (ERA)

The remittance advice submitted to the provider electronically is called this.

noncovered benefit

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.

unauthorized service

Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization.

Electronic Funds Transfer (EFT)

When payers deposit funds to the provider's account electronically.

source document

Routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated.

open claim

Organized by month and insurance company and have been submitted to the carrier, but processing is not complete.

closed claim

Filed according to year and insurance company and include those for which all processing, including appeals, has been completed.

unassigned claim

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.

pre-existing condition

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.

accounts receivable

The amounts owed to a business for services or good provided.

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.

covered entity

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.

clean claim

Contains all required data elements needed to process and pay the claim (e.g., valid diagnosis and procedure/service codes, modifiers, and so on.

claims attachment

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.

claims processing

Involves sorting claims upon submission to collect and verify information about the patient and the provider.

claims adjudication

When the claim is compared to payer edits and the patients health plan benefits to make certain verifications.

common data file

An abstract of all recent claims filed on each patient.

allowed charges

The maximum amount the payer will allow for each procedure or service, according to the patient's policy.

deductible

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.

coinsurance

The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.

beneficiary

The person in whose name the insurance policy is issued.

accept assignment

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.

guarantor

Person responsible for paying the charges

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.

primary insurance

The insurance plan responsible for paying health care insurance claims first.

birthday rule

States the policholder whose birth month and day occurs earlier in the calendar year holds the primary policy for dependent children.

encounter form

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.

superbill

This is what the encounter form is called in the physician's office.

chargemaster

This is what the encounter form is called in the hospital.

patient ledger

A permanent record of all financial transactions between the patient and the practice.

patient account record

The patient ledger in a computerized system is called this.

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.

claims submission

The transmission of claims data (electronically or manually) to payers or clearinghouses for processing.

clearinghouse

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).

accounts receivable aging report

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ANSI ASC X12 standards

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appeal

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assignment of benefits

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bad debt

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Consumer Credit Protection Act of 1968

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day sheet

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delinquent account

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delinquent claim

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delinquent claim cycle

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downcoding

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electronic data interchange (EDI)

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Electronic Funds Transfer Act

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electronic media claim

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Equal Credit Opportunity Act

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Fair Credit and Charge Card Disclosure Act

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Fair Credit Billing Act

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Fair Credit Reporting Act

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Fair Debt Collection Practices Act (FDCPA)

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litigation

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out-of-pocket payment

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outsource

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past-due account

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Provider Remittance Notice (PRN)

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suspense

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Truth in Lending Act

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two-party check

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unbundling

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