assignment of benefits
the transfer of the patient's legal right to collect benefits for medical expenses to the provider of whose services; the patient athorizes sending of the payment directly to the provider
an insurance claim form that has been completed correctly (no errors or omissions); clean claims can be processed and paid promptly if they meet the restrictions on covered services and blocks.
a centralized facility to which insurance claims are transmitted. Clearinghouse separate, check, and redistribute claims electronically to various insurance carriers and may offer additonal services to the physician
a claim submitted to an insurance processing facility through a computerized medium, such as direct data entry, direct wire, dial-in telephone digital fax, or personal computer download or upload.
electronic data interchange (EDI)
The transfer of data back and forth between two or more entities using an electronic medium.
employer indentification number (EIN)
The number used by the Internal Revenue Service to identify a business or individual functioning as a business entity for income tax reporting
National Provider Indentifier (NPI)
a lifetime number consisting of 10 digits that Medicare uses to replace the Provider Identification Number (PIN) and the Unique Physician Identification Number (UPIN)
intelligent character recognition (ICR)
The electronic scanning of printed items as images and use of special software to recognize these images (or characters) as ASCII text for upload into a computer database.
Unique Provider Identification Number (UPIN)
A number assigned by fiscal intermediaries to identify providers on claims for services
universal claim form
The form used to submit all government sponsored claims; also know as the CMS-1500 form. It was developed by the agency that became the Centers for Medicare and Medicaid Services (CMS) and approved by the American Medical Association (AMA).
Additional services typically provided by clearinghouses include:
1. reporting the number of claims
2. forwarding claims
3. keeping provider updated
4. generating reports
A medical assistant may submit insurance claims to a third-party payer or an insurance carrier on:
hard copy (paper) or electronically.
The CMS-1500 form has 33 blocks, or items, which are divided into three sections:
Section 1: Carrier Block (contains the address of the insurance carrier)
Section 2: Patient/Insured Section (contains information about the patient and the insured)
Section 3: Physician/Supplier Section (contains information about the physician or supplier)
Three most common types of claims are:
1. Clean claim- complete and accurate claim
2. Dirty claim- inaccurate or incomplete
3. Rejected claim- a claim for which payment has been denied for any reason
AN ORGANIZATION UNDER CONTRACT TO THE GOVERNMENT AS WELL AS SOME PRIVATE PLANS TO ACT AS FINANCIAL REPRESENTATIVES IN HANDLING INSURANCE CLAIMS FROM PROVIDERS OF HEALTH CARE ALSO REFERRED TO AS FISCAL INTERMEDIARY
An older method of tracking patient accoundt that allows the figures to be proved accurate through mathermatic formulas. It is sitll use on some small to medium practices; also caled the whrite-it-once system
a person to whom property is legally committed to be administered for the benefit of a beneficiary or held by an administrator to be distributed to multiple individuals or businesses
Most healthcare payers use the CMS-1500 Health Insurance Claim Form for claims submitted by physicians and suppliers.
The information needed to complete the form includes the patient's and guarantor's demographic and insurance company; the diagnostic, treatment, and procedures and services information; and the provider's billing information, including name, address, phone number, place of service, and the tax and provider ID numbers.
The ______________ will audit the claims, sort them, and then send them in batches electronically to the aplicable insurance carriers.
Two common reasons claims are rejected are:
1. a procedure listed on the claim is not a covered service
2. the insurance payer considers the procedure a pre-existing condition
Most insurance plans base their payments on a usual, customary, and reasonable (UCR) fee
Usual- the physican's usual fee for a given service
Customary- a range of the usual fee charged for the same by physician's with similar training and experience who practice in teh same geographic and socioeconomic area
Reasonable- the fee for an exceptionally difficult or complicated service or procedure that requires extraordinary time or effort by the physician
payment for medical services is accomplished in the following four ways:
4. Billing assistance
the________________________ requires that debt collectors act fairly in their collection efforts; it also restricts how and when a person can be contracted about an outstanding debt
Fair Debt Collection Practices Act
In the past, many physicians did not charge profeesional collegues or their close family members for medical care; this concept is called ____________ _____________
When a statement is returned marked :moved- no forwarding address" you may consider this account as a ________.
Physician often send their _________ or _______ ________ with records of unpaid accounts to show the judge
bookkeeper or medical assistant
banking through the use of mobile devices, such as cell phones and wireless internet services.
power of attorney
a legal statement in which a person authorizes another person to act as his or her attorney or agent. The authority may be limited to the handling of specific procedures. The person authorized to act as the agent is known as the attorney in fact.
a capital sum of money due as a debt or used as a fund for which interest is either charged or paid.
uniform commercial code (ucc)
A unified set or rules covering many business transactions; it has been adopted n all the states, the District of Columbia, and most U.S. territories. It regulates the fields of sales of goods; commercial paper, such as checks; secured transactions in personal property; and particular aspects of banking, letters of credit, warehouse receipts, bills of lading, and investment securities.
Congress created the ____________ ___________ in _____ as the central bank of the United States.
Federal Reserve; 1913
To cover their overhead cost, most banks currently charge both the payer and payee a fee of $10 to $35 for a check that has been returned because of __________ ________. This is called ________ _______.
insufficient funds; charging fees