UHB Review of Chapter 4 Glossary

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Understanding the Glossary

Accounts Receivable (A/R) Aging Report

A report outlining categories of claims based on the age of the account.

Admission

The act of being received into a place or patient accepted for inpatient services in a hospital

Admission Evaluation Protocol (AEP)

Outlines appropriate conditions for a hospital admission based on standards referred to as the IS/SI criteria. IS refers to the intensity of service criteria. SI refers to the severity of illness criteria.

Admission Summary

A summary of information about the patients admission, such as the patient's name, address, insurance company name, reason(s) for admission, attending physicians name, and referring physicians name. The admission summary is also known as a Fact Sheet.

Advance Beneficiary Notice (ABN)

A notice informing the patient that there is a reason to believe the admission will not be covered by Medicare. The patients signature is required on this form to acknowledge that he or she will be financially responsible if Medicare does not cover the service.

Advance Directive

Provide instruction regarding measures that should not be taken in he event medical treatment is required to prolong life.

Ambulatory Payment Classification (APC)

A prospective payment system (PPS) implemented to provide reimbursement for hospital outpatient services. Under APC, the facility is paid a fixed fee based on resources utilized to provide the services or procedure.

Assignment of Benefits

Instructs the insurance company or Government plan to forward benefits (payments for services) to the hospital.

Charge Capture

The process of gathering charge information and recording it on the patients account.

Charge Description Master (CDM)

A computerized system utilized by the hospital to inventory and record services and items provided by the hospital. CDM is commonly referred to as the Chargemaster.

CMS-1450 (UB-04)

Universally accepted claim form used ro submit facility charges for hospital inpatient and outpatient services.

CMS-1500

Universally accepted claim form for submission of physician and outpatient services and Durable Medical Equipment (DME).

Co-insurance

An amount the patient is responsible to pay that is calculated on a on a percentage based on a percentage of approved charges.

Co-payment

A set amount that is paid by the patient for specific services. Co-payment is commonly referred to as a copay.

Concurrent Review

Ongoing review throughout the hospital stay to determine appropriateness of the admission and care provided.

Deductible

An annual set amount determined by each payer that the patient must pay before the plan pays benefits.

Encounter Form

A charge tracking document utilized to record services, procedures, and items provided during the visit and the medical reasons for the services.

Explanation of Benefits (EOB)

Another term used for remittance advice.

Explanation fo Medicare Benefits (EOMB)

Another term used for remittance advice.

Facility Charges

Charges that represent the cost and overhead for the technical component of patient care, services, which include space, equipment, supplies, drugs and biologicals, and technical staff.,

Financial Class

A classification of patient accounts and information such as charges, payments, and outstanding balances, grouped according to payer types.

Guarantor

The individual who is responsible to pay for the services provided.

Informed Consent for Treatment

A form utilized by the hospital to obtain the patients authorization for treatment. The form must be signed by the patient before treatment can be provided.

Insurance Verification

The process of contacting the patients insurance plan to determine various aspects of coverage such as whether the patient's coverage is active, what services are covered, authorization requirements, and patient responsibility.

Medical Necessity

Services and procedures that are responsible and medically necessary in response to the patients symptoms according to standards of medical practice.

Medical Record

A chart or folder is stored including demographic, insurance, and medical information.

Medical Record Number (MRN)

A unique identification number assigned to each patients medical record. The MRN remains the patients medical record number indefinitely.

Medical Severity Diagnosis Related Groups (MS-DRG)

A medical reimbursement method implemented under PPS that pays hospitals a fixed amount for a hospital stay based on the patients diagnosis and the severity of that condition.

Patient registration Form

A form utilized by the hospital to obtain the patients information including demographic, insurance, and financial information.

Professional Charges

Charges that represent physician and other non-physician clinical services, the professional component of patient care services.

Prospective Review

A review performed prior to the patient admission to determine appropriateness of the admission and length of stay.

Remittance Advice (RA)

A document prepared by payers to communicate payment determination to hospitals and patients. The RA includes detailed information about the charges and an explanation of how the claim was processed.

Retrospective Review

A review conducted after a patient is discharged to determine the appropriateness of admission and care provided.

Written Authorization for Release of Medical Information

Provides authorization for the hospital to release personal health information when required for treatment and to obtain payment for services.

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