understanding health insurance

69 terms by sheila123 

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cms-1500

the insurance claim form used to report professional services

accept assignment

when the provider agrees to accept what the insurance company allows or aproves as payment in full for the claim

accounts receivable management

assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verfication/eligibility and preauthorization of services

accounts receivable aging report

shows the status (by date) of outstanding claims from each payer, as well as payments due from patients

accounts receivable

the amount owed to a business for services or goods provided

allowed charges

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

ANSI ASC X12 standards

uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims.

appeal

documented as a letter, signed by the provider, explaining what a claim should be reconsidered. for payment.

assignment of benefits

the provider receives reimbursement directly from the payer.

bad debt

accounts receivable that cannot be collected by the provider or a collect agency.

beneficiary

the person eligible to receive healthcare benefits.

birthday rule

determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.

chargemaster

the term hospital use to describe the encounter form.

claims adjudication

comparing a claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicated; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.

claims attachment

medical report substantiating a medical condition

claims processing

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

claims submission

the transmission of claims data (electronical or manually) to payers or clearinghouses for processing.

clean claim

a correctly completed standardized claim

clearinghouse

is a public or private entity that processes of facilitates the processing of nonstandard data elements into standard data elements.

closed claim

claims for which all processing, including appeals, has been completed.

coinsurance

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

common data file

abstract of all recent claims filed on each patient.

Consumer Credit Protection Act of 1968

was considered the landmark legislation because it launched truth in lending disclosures that reguired creditors to communicate the cost of borrrowing money in a common language so that consumers could figure out the charges, compare cost, and shop for the best credit deal.

coordination of benefits (COB)

provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies: also specifies that coverage will be provided in a specified sequence when more than one policy covers the claim.

covered entity

health plans, healthcare clearinghouses, government health plans, and any health providers that choose to submit or receive transactions electronically.

day sheet

also called manual daily accounts receivable journal; cronological summary of all transactions posted to individual patient legers/accounts on a specific day.

deductible

amount for which the patient is financially responsible before an insurance company provides coverage.

delinquent account

is a past due account; one that has not been paid within a certain time frame.

deliquent claim

a claim that is usually more than 120 days past due; some practices establish time frames that are less than 120 days.

delinquent claim cycle

advances through various aging periods( 30,60,90,120) with practices typically focusing internal recovery efforts on older delinquent accounts.

downcoding

assigning lower-level codes then documented in the record.

electronic data interchange EDI

computer to computer data exchange between payer and provider

electronic flat file format

series of fixed length records submitted to payers to bill for health care services.

electronic funds transfer

system by which payers deposit funds to the providers account electronically.

electronic funds transfer ACT

establishes the rights. liabilites, and rsponsibilities of participants in electronic funds transfer systems.

Electronic Healthcare Network Accreditation Commission EHNAC

organization that accredits clearinghouses

electronic media claim

series of fixed length records submitted to payers to bill for health care services.

electronic remittance advice

remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive ERA more quickly.

encounter form

financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter.

Equal Credit Opportunity ACT

prohibits discrimination on the basis of race, color, religion, national origin, sex, martial status, age, reciept of public assistance, or good faith exercise of any rights under the Cunsumer Credit protection ACT.

Fair Credit and Charge Card Disclosure ACT

amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and any other application and solicitations for open-end credit and charge accounts and under other circumstances; this law applies to providers that accept credit cards.

Fair Credit Billing Act

federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of account, and charges for unsatisfactory goods and services; cardholders cannot be held liable for more than $50 of fraudulent charges made to a credit card.

Fair debt collection practicies Act

specifies what a collection source may or may not do when pursuing payment on past due accounts.

guarantor

person responsible for paying healthcare fees

litigation

legal action to recover a debt; usually a last resort for a medical practice.

manual daily accounts receivable journal

also called a day sheet, a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.

noncovered benefit

any procedure or service reported on a claim that is not included on the payers master benefit list, resulting in denial of the claim; also called noncovered procedure or uncoverd benefit.

nonparticipating provider

does not contract with the insurance plan; patient who elects to recieve care from nonPARS will incur higher out-of-pocket expenses.

open claim

submitted to the payer, but processing is not complete

out-of-pocket payment

established by health insurance companies for a health insurance plan; usually has limits of $1000 or $2000; when the patient has reached the limit of an out-of-pocket payment (deductable) for the year, appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket apyment provision

outsourcing

contract out

participating provider

contracts with a helath insurance plan and accepts whatever the plan pays for procedures or services performed.

past-due account

one that has not been paid within a certain time frame; also called delinquent account

patient account record

a computerized permanent record of all financial transactions between the patient and the pratice, also called patient ledger.

patient ledger

a computerized permanent record of all financial transactions between the patient and the practice;also called patient account record.

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.

primary insurance

associated with how an insurance plan is billed-the insurance plan responsible for paying healthcare insurance claims first is considered primary.

Provider Remittance Notice

remittance advice submitted by Medicare to providers that includes payment information about a claim.

source document

a routing slip, charge slip, encounter form, or suberbill from which the insurance claim was generated.

superbill

term used for the encounter form in the physicians's office.

suspense

pending

two-party check

a check made out to the patient and the provider.

unassigned claim

are organized by year; generated for providers who do not accept assignment; includes all unassigned claims for which the provider is not obligated to perform any follow-up work.

unauthorized service

services that are provided to a patient without proper authorization or that are not covered by a current authorization.

unbundling

submitting multiple CPT codes when one code could of been submitted.

value-added network VAN

clearinghouses that involves value-added vedors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers than managing their own systems to send and receive transactions directly from nummerous entities.

electronic claim processing

sending data in a standardized machine readable format to an insurance company via disk, telephone or cable.

Fair credit reporting Act

protects information collected by consumers reporting agencies such as credit bureaus, medical information companies and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligation, including the duty to investigate disputed information.

UB-04

form used to report institutional, facility services.

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