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29 terms

mod5 admin terms

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accounting cycle
the flow of financial transactions in a business
accounts receivable
money coming into the business
adjudication
series of steps that determine whether a claim should be made
billing cycle
regular schedule of sending statements to patients
capitation
advance pymts to a provider that covers each plan member's health care services for a certain period of time
coding
the process of assigning standardized codes to diagnoses and procedures
coinsurance
the part of charges that an insured person must pay for health care services after pymt of deductible
consumer-driven health plan-CDHP
a type of managed care in which a high deductible/low premium insurance plan in combined with a pretax savings account to cover out-of -pocket expenses
copayment
a small fixed fee paid by the patient at the time of an office visit
diagnosis code
a standardized value that represents a patient's illness, signs and symptoms
encounter form
a list of procedures and charges for a patient's visit
explanation of benefits EOB
paper document from insurance company that shows how the amount of a benefit was determined
fee-for-service
health plan that repays the policyholder for covered medical expenses-common in traditional plans
health maintenance organization-HMO
a managed health care system in which providers agree to health care for the HMO's members for fixed payments from the plan
health plan
a plan, program or organization that provides health care benefits
managed care
a type of health coverage where the carrier is responsible for both the financing and delivery of health care
medical coder
a person who analyzes and codes patient diagnoses, procedures and symptoms
medical necessity
treatment provided by a physician to a patient for the purpose of preventing, diagnosing or treating an illness, injury or its symptoms in a manner that is approriate to generally accepted standards
patient information form
a form that includes a patient's personal, employment and insurance data needed to complete the insurance claim
payer
private or government organization that insures or pays for health care on the behalf of the beneficiaries
policyholder
any person who buys an insurance plan; the insured
practice management program-PMP
a software program that automates many of the administrative and financial tasks required to run a medical practice
preferred provider organization-PPO
a managed health care system where a network of providers agree to perform services to plan members at a discounted fee
premium
the amount the insured pays for insurance coverage
procedure
medical treatment provided by a physician or other health care provider
procedure code
a code that identifies a medical service
remittance advice-RA
an explanation of benefits (EOB) transmitted electronically
statement
a list of all services performed for a patient, along with the charges for each service
diagnosis
physician's opinion of the nature of the patient's illness or injury