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69 terms

understanding health insurance

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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.