Chapter 4: Processing an Insurance Claim

Created by Redfroggy 

Upgrade to
remove ads

Accept assignment

provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).

Accounts receivable

the amount owed to a business for services or goods provided.

Allowed charges

maximum fee a physician may charge. Also called a limiting charge.

Assignment of benefits

the provider receives reimbursement directly from the payer.

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

term hospitals use to describe a patient 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 duplicate; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.

Claims processing

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

Clean claim

a correctly completed standardized claim (e.g., CMS-1500 claim).

Clearinghouse

performs centralized claims processing for providers and health plans.

Day sheet

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

Deductible

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

Delinquent claim

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

Electronic data interchange (EDI)

computer-to-computer exchange of data between provider and payer.

Electronic funds transfer (EFT)

system by which payers deposit funds to the provider's account electronically.

Electronic remittance advice (ERA)

remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the 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 basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good faith exercise of any rights under the Consumer Credit Protection Act.

Fair Credit Reporting Act

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

Guarantor

person responsible for paying healthcare fees.

Participating provider (PAR)

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

Pre-existing condition

any medical condition that was diagnosed and/or treated within a specific period of time immediately preceding the enrollee's effective date of coverage.

Superbill

term used for an encounter form in the physician's office.

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set