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Patient to Payment Chapters 1-14
Terms in this set (347)
accounts payable (AP)
The practice's operating expenses, such as overhead, salaries, supplies, and insurance.
accounts receivable (AR)
Monies owed to a medical practice by its patients and third-party payers.
The amount of money a health plan pays for services covered in an insurance policy.
The movement of monies into or out of a business
The recognition of a person demonstrating a superior level of skill on a national test by an official organization
The process of translating a description of a diagnosis or procedure into a standardized code
The portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage
An amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter
Medical procedures and treatments that are included as benefits under an insured's health plan
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
The physician's opinion of the nature of the patient's illness or injury
The systematic, logical, and consistent recording of a patient's health status - history, examinations, tests, results of treatments, and observations - in chronological order in a patient medical record
electronic claim (e-claim)
Health care claims that are sent electronially.
electronic health record (EHR)
A computerized lifelong health care record with data from all sources.
Method of charging under which a provider's payment is based on each service performed.
health care claim
An electronic transaction or paper document filed with a health plan to receive benefits.
health information techonology (HIT)
Computer hardware and software information systems that record, store, and manage patient information
Under HIPPA, and individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers; health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans
An insurance company's agreement to reimburse a policyholder a predetermined amount for covered losses.
System that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
managed care organizaiton (MCO)
Organization offering some type of managed health care plan.
An administrative medical employee.
medical billing cycle
A ten-step process that results in hospital and medical care.
medical documentation and billing cycle
A combination of the billing cycle and medical documentation cycle of a practice, which explains how using EHRs is integrated with practice management programs.
Financial plan that covers the cost of hospital and medical care.
Medical treatment that is appropriate and rendered in accordance with generally accepted standards of medical practice; the place of service must also be appropriate for the diagnosis and care provided.
noncovered (excluded) services
Medical procedures that are not included in a plan's benefits.
Expenses the insured must pay before benefits begin.
Software program that combines both a PM and an EHR in a single product.
Person who buys an insurance plan; the insured, subscriber, or guarantor.
practice management program (PMP)
Business software designed to organize and store a medical practice's financial information; often includes scheduling, billing, and electronic medical records features.
Prior authorization from a payer for services to be provided; if preauthorization for hospital is not received, the charge is usually not covered.
Money the insured pays to a health plan for a helath care policy.
The services and treatments performed by a practice.
Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
remittance advice (RA)
Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB).
revenue cycle management (RCM)
All the actions that help to ensure that the provider receives maximum appropriate payment for services.
A report that shows the services provided to a patient, total payments made, total charges, adjustments, and balance due.
Private or government organization that insures or pays for health care on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
Acknowledgement of Receipt of Notice of Privacy Practices
Form accompanying a covered entity's Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgement.
assignment of benefits
Authorization by a policyholder that allows a health plan to pay for benefits directly to a provider
The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary.
Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the prior authorizaiton number.
Office procedures that ensure that billable services are recorded and reported for payment
A unique number that identifies a patient.
coordination of benefits (COB)
A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim
A list of the diagnoses, procedures, and charges for a patient's visit; also called the superbill
established patient (EP)
Patient who has received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
Coordination of benefits rule for a child insured under both parents' plans under which the father's insurance is primary.
A person who is the insurance policyholder for a patient of the practice.
HIPAA Coordination of Benefits
The HIPAA ASCX12N 837 transaction that is sent to a secondary or tertiary payer on a claim with the primary payer's remittance advice.
HIPAA Eligibility for a Health Plan
The HIPAA X12N 270/217 transaciton in which a provider asks a health plan for approval of a service and the health plan responds, providing a certification number for an approved request.
HIPAA Referral Certification and Authorization
The HIPAA X12N 278 transaction in which a provider asks a health plan for approval of a service and the health plan responds, providing a certification number for an approved request.
The policyholder or subscriber to a health plan or medical insurance policy; also known as a guarantor.
A group of providers in a managed care organization that allows patients to avoid paying higher charges.
new patient (NP)
A patient who has not received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
nonparticipating provider (nonPAR)
A provider who chooses not to join a particular government or other health plan.
A provider that does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan's enrollees.
participating provider (PAR)
A provider who agrees to provide medical services to a payer's policyholders according to the terms of the plan's contract.
patient information form
Form that includes a patient's personal, employment, and insurance company data needed to complete a health care claim; also known as a registration form.
Health plan that pays benefits first when a patient is covered by more than one plan.
prior authorization number
Identifying code assigned by a government program or helath insurance plan when preauthorizaiotn is required; also called the certification number.
Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending.
The physician who refers the patient to another physician for treatment.
The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan.
Insurance plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan.
The third payer on a claim.
A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits.
The section of the ICD-10-CM in which diseases and injuries with corresponding diagnosis codes are presented in alphabetical order.
A three-character code used to classify a particular disease or injury.
chief complaint (cc)
A patient's description of the symptoms or other reasons for seeking medical care from a provider.
A single code that classifies both the etiology and the manifestaton(s) of a particular condition.
Typographic technique or standard practice that provides visual guidelines for understanding printed material
A physician's description of the main reason for a patient's encounter; may also describe related conditions or symptoms.
A name or phrase that is formed from or based on a person's name; usually describes a condition or procedure associated with that person.
The cause or origin of a disease.
Entries in the Tabular List limiting applicability of particular codes to specified conditions.
external cause code
An ICD-10-CM code for an external cause of a disease or injury.
Acronym for general equivalent mappings, reference tables of related ICD-10-CM and ICD-9-CM codes prepared by the federal government.
The previously HIPAA-mandated diagnosis code set.
The HIPAA-mandated diagnosis code set as of October 1, 2014.
ICD-10-CM Official Guidelines for Coding and Reporting
The general rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS).
Entries in the Tabular List addressing the applicability of certain codes to specified conditions.
Index to External Causes
Reference listing all the external causes of diseases and injuries that are listed in the related chapter of the Tabular List.
The use of the ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s).
The word that identifies a disease or condition in the Alphabetic Index.
Characteristic sign or symptom of a disease.
NEC (not elsewhere classified)
An abbreviation indicating the code to be used when a disease or condition cannot be placed in any other category.
Reference that provides code numbers for neoplasms by anatomical site and divided by the description of the neoplasm
A supplementary word or phrase that helps define a code in ICD-10-CM.
NOS (not otherwise specified)
An abbreviation indicating the code to be used when no information is available for assiging a disease or condition a more specific code.
A patient who receives health care in a hospital setting without admission; the length of stay is generally less than twenty-three hours.
placeholder character (x)
A character "x" that is inserted in a code to fill a blank space
Problems that result form a previous disease or injury.
The necessary assignment of a seventh character to a code; often for the sequence of an encounter.
A four- or five-character code number.
Word or phrase that describes a main term in the Alphabetic Index.
Table of Drugs and Chemicals
A reference in table format listing drugs and chemicals in teh Tabular List.
Part of ICD-10-CM in which diagnosis codes are listed in chapters alphanumerically.
The abbreviation for codes form the twentieth chapter of the ICD-1-CM that identify factors that influence health status and encounters that are not due to illness or injury.
Procedure that is performed and reported only in addition to a primary procedure, indicated in CPT by a plus sign (+)
The procedure code for a surgical package that covers a group of services that should not be listed individually
Category I code
Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology, and Laboratory, Radiology, and Medicine).
Category II code
Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use.
Category III code
Temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available.
The connection between a service and a patient's condition or illness; establishes the medical necessity of the procedure.
Service performed by a physician to advise a requesting physician about a patient's condition and care; the consultant does not assume responisbility for the patient's care and must send a written report back to the requestor.
Current Procedural Terminology (CPT)
Publicaiton of the American Medical Association containing the HIPAA-madated standardized classification system for reporting medical procedures and services perormed by physicians
Procedure codes that cover physicians' services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT
A name or phrase that is formed from or based on a person's name; usually describes a condition or procedure associated with that peson.
The number of days surrounding a surgical procedure during which all services relating to the procedure - preoperative, during the surgery, and postoperative - ar considered part of the surgical package and are not additionally reimbursed.
Health Care Common Procedure Coding System (HCPCS)
Procedure codes for Medicare claims, made up of CPT codes (Level I) and national codes (Level II).
Factor required to be documented for various levels of evaluation and management services.
level of service
The amount of work, time, and decision making invloved in an encounter.
A five-digit number to which one or more two-digit CPT modifiers may be assigned.
A moderate, drug-induced depression of consiousness during which patients can respond to verbal commands.
A number that is appended to a code to report particular facts. CPT modifiers report special circumstances involved with a procedure or service.
In CPT, a single code grouping laboratory tests that are frequently done together.
place of service (POS)
HIPAA administrative code that indicates where medical services were provided.
The most resource-intesive (highest paid) CPT procedure done during a patient's encounter.
Code that identifies medical treatment or diagnostic services.
The transfer fo patient care from one physician to another.
CPT procedure codes that have been reasigned to another sequence, or CPT range of codes.
Usage notes provided at the beginnings of CPT sections.
Descriptor in the Surgery Section of CPT for a procedure that is usually part of a surgical package but may also be performed separately or for a different purpose, in which case it may be billed.
Combination of services included in a single procedure code for some surgical proceduers in CPT.
The incorrect billing practice of breaking a panel or package of services/procedures into component parts and reporting them separately.
Services that are not listed in CPT; they are reported with an unlisted procedure code and require a special report when used.
A participating physician's agreement to accept the allowed charge as payment in full.
A change to a patient's account, such as a returned check fee.
The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured.
A single predetermined payment for an entire episode of care.
The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
Payment mthod in which a prepayment covers the provider's services to a plan member for a specified period of time.
consumer-driven health plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
Dollar amount used to multiply a relative value unit to arrive at a charge.
A negotiated payment schedule for health care services based on a reduced percentage of a provider's usual charges.
A list of the usual fees a physician charges for procedures and services.
a practice's rules governing payment from patients for medical services.
flexible savings account (FSA)
Type of consumer-riven health plan funding option that has employer and employee contributions; funds left over revert to the employer.
health maintenance organization (HMO)
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
health reimbursement account (HRA)
Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of health care costs.
health savings account (HSA)
Type of consumer-driven-health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of health care costs.
high-deductible health plan (HDHP)
Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients' out-of-pocket expenses up to the deductible.
independent practice association (IPA)
Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.
The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the health care sustem.
Medicare Physician Fee Schedule (MPFS)
The RBRVS-based allowed fees that are the basis for Medicare reimbursement.
A patient payment made during the checkout process based on an estimate by the practice of what the patient will owe.
per member per month (PMPM)
Periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits.
point-of-service (POS) plan
In HMOs, a plan that permits patients to receive medical services from non-network providers; this choice requires a larger patient payment than visits with network providers.
preferred provider organization (PPO)
Managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
primary care physician (PCP)
A physician in a health maintenance organization who directs all aspects fo a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
resource-based relative value scale (RBRVS)
The payment system used by Medicare to establish relative value units for services based on resources.
real-time claims adjudication (RTCA)
A process used to generate the actual amonut owed by a patient, as opposed to an estimate of that amount.
A patient who does not have insurance coverage.
UCR (usual, customary, reasonable)
Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.
Medical billing program report given to patient that lists the diagnosis, services provided, fees, and payments received and due after an encounter.
To deduct an amont from a patient's account because fo a contractual agreement to accept a payer's allowed charge or for other reasons.
The format for electronic claims
The HIPAA-mandated electronic transaction for claims; also called HIPAA claim.
administrative code set
Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.
The person or organization (often a clearinghouse or billing service) sending a HIPAA claim as distinct fromt eh pay-to provider who receives payment
Data entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer.
Documentation that a rppvider sends to a payer in support of a health care claim.
claim control number
Unique number assigned to a health care claim by the sender
claim filing indicator code
Administrative code used to identify the type of health plan.
claim frequency code (claim submission reason code)
Administrative code that identifies the claim as original, replacement, or void/cancel action.
A claim tat is accepted by health lan for adjudicaiton.
Paper claim for physician services.
The NUCC-revidsed paper claim with modified instrucitons.
Two-digit numeric or alphanumeric codes used to report a special condiiton or unique circumstance about a claim.
A collection of related facts.
The smallest unit of information in a HIPAA transaction.
In HIPAA claims, the health plan receiving the claim.
electronic transaction for claims also called the 837P claim.
individual relationship code
Administrative code that specifies the patient's relationship to the subscriber (insured)
line item control number
On a HIPAA claim, th unique number assigned by the sender to each service line item reported.
National Uniform Claim Committee (NUCC)
Organization responsible for the content of health care claims.
Purchased laboratory services.
The person or organizationthat is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider.
place of service (POS) code
HIPAA administrative code that indicates where medical services were provided.
2-digit code ffor a type of provider identificaiton number other than the NationalProvider Identifier (NPI)
Term used to identify the physicia or other medical professional who provides the procedure reported on ahealth care claim if other than the pay-to-provider.
Claims sent to a secondary payer reporting what the primary payer paid on the claim.
service line information
On a HIPAA claim, information about the services being reported.
Administrative code set under HIPAA used to report a physician's specialty when it affects payment.
Claims sent to a tertiary payer reporting what the primary and secondary payers paid on the claim.
advance beneficiary notice of noncoverage (ABN)
Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program
CPT code combinations that are used by computers in the Medicare system to check claims
Correct Coding Initiative (CCI)
Computerized Medicare system to prevent payment for procedures
Claims for a Medicare or Medicaid beneficiary; Medicare is the primary payer and automatically trensmits claim information to Medicaid as the secondary payer
a list of health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists
health insurance claim number (HICN)
A Medicare beneficiary's identification number; appears on the Medicare card.
Internet-Only Manuals (IOM)
Medicare's collection of manuals that have day-to-day operation instructions, policies, and procedures based on statutes and regulations
In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service
local coverage determination (LCD)
Notices sent to physicians that contain detailed and updated information about the coding and medical necessity of a specific Medicare Service
Medical Savings Account (MSA)
The Medicare health savings account program
medically unlikely edits (MUEs)
CMS-established units of service edits used in order to lower the Medicare fee-for-service paid claims error rate
The federal health insurance program for people who are 65 or older
Medicare administratice contractor (MAC)
The contractors who handle claims and related functions for both Medicare Parts A and B
Medicare plans other than the Original Medicare Plan
A person who is covered by Medicare
Medicare Integrity Program (MIP)
A CMS program designed to identify and address fraud, waste, and abuse.
Medicare Learning Network (MLN)
An online collection of articles that explain all Medicare topics
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home care, and hospice
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies
Medicare Part C
Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program
Medicare Part D
Prescription drug reimbursement plans offered to Medicare beneficiaries
Medicare Remitttance Notice (MRN)
The RA that the office receives from Medicare
Medicare Secondary Payer (MSP)
Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries' claims
Medicare Summary Notice (MSN)
Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined
Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage
Person who is eligible for both Medicare and Medicaid benefits
national coverage determination (NCD)
Medicare policy stating whether and under what circumstances a service is covered by the Medicare program
Original Medicare Plan
The Medicare fee-for-service plan
Physician Quality Reporting System (PQRS)
A voluntary quality reporting program established by CMS in which physicians or other eligible professionals collect and report their practice data in relation to a set of patient-care performance measures that are established annually
The Medicare law requiring claims to be filed within one calendar year after the date of service
urgently needed care
In Medicare, a beneficiary's unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan's service area
A person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF).
Children's Health Insurance Program (CHIP)
Program offering health insurance coverage for uninsured children under Medicaid
Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
Medicaid's prevention, early detection, and treatment program for eligible children under the age of 21.
Federal Medicaid Assistance Percentage (FMAP)
Basis for federal government Medicaid allocations to individual states.
An organization that processes calims for a government program, such as Medicaid.
Program that pays for health care services for people with incomes below the national poverty level.
California's Medicaid program.
Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance; medically needy.
Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance; medically indigent.
payer of last resort
Regulation that Medicaid pays last on a claim when a patient has other insurance coverage.
Temporary Assistance for Needy Families (TANF)
Government program that provides cash assistance for low-income families
The obligation of a government program or insurance plan to pay all or part of a patient's medical costs.
Welfare Reform Act
A 1996 law that established the Temporary Assistance for Needy Families program in place of Aid to Families with Dependent Children program and that tightened Medicaid eligibility requirements.
The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share.
Under TRICARE, a geographic area served by a hospital, clinic, or dental clinic and usually based on Zip codes to set an approximate 40-mile radius of military inpatient treatment facilities.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
The Civilian Health and Medical Program of the Department of Veterans Affairs (previously known as the Veterans Administration) that shares health care costs for families of veterans with 100 percent service-connected disablilites and the surviving spouses and children of veterans who die from service-connected disabilities.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Now the TRICARE program; formerly the Civilian Health and Medical Program of the Uniformed Services (Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration) that serves spouses adn children of active-duty service members, military retirees and Civilian Health and Medical Program of the Department of Veterans Affairs.
Coinsurance for a TRICARE or CHAMPVA beneficiary.
Defense Enrollment Eligibility Reporting System (DEERS)
The worldwide database of TRICARE and CHAMPVA beneficiaries.
Military Treatment Facility (MTF)
Government facility providing medical services for members and dependents of the uniformed services.
nonavailability statement (NAS)
A form required for preauthorization when a TRICARE member seeks medical services in other than military treatment facilities.
Primary Care Manager (PCM)
Provider who coordinates and manages the care of TRICARE beneficiaries.
The uniformed service member in a family qualified for TRICARE and CHAMPVA.
Government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.
TRICARE's managed care health plan that offers a network of civilian providers.
TRICARE for Life
Program for beneficiaries who are both Medicare and TRICARE eligible.
The basic managed care health plan offered by TRICARE.
TRICARE Prime Remote
Program that provides no-cost health care through civilian providers for service members and their families who are on remote assignment.
TRICARE Reserve Select (TRS)
TRICARE coverage for reservists.
The fee-for-service health plan offered by TRICARE.
Admission of Liability
Carrier's determination that an employer is responsible for an employee's claim under worker's compensation.
automobile insurance policy
A contract between an insurance company and an individual, under which the individual pays a premium in exchange for coverage of specified car-related financial losses.
disability compensation programs
Programs that provide partial reimbursement for lost income when a disability - whether work-related or not - prevents an individual from working.
Federal Employees' Compensation Act (FECA)
A federal law that provides worker's compensation insurance for civilian employees of the fedreal government.
Federal Insurance Contribution Act (FICA)
The federal law that authorizes payroll deductions for the Social Security Disability Program.
A report filed by the physician in a state workers' compensation case when the patient is discharged.
first report of injury
A report filed in state workers' compensation cases that contains the employer's name and address, employee's supervisor, date and time of accident, geographic location of injury, and patient's description of what happened
independent medical examination (IME)
Examination by a physician to confirm that an individual is permanently disabled that is conducted at the request of a state workers' compensation office or an insurance carrier.
A written, legal claim on property to secure the payment of a debt.
Notice of Contest
Carrier's determination to deny liability for an employee's worker's compensation claim
occupational diseases or illnesses
Conditions caused by the work environment over a period longer than one workday or shift; also known as nontraumatic injuries.
Occupational Safety and Health Administration (OSHA)
A program created by Congress in 1970 to protect workers from health and safety risks on the job.
Office of Workers' Compensation Programs (OWCP)
A part of the U.S. Department of Labor that administers programs to cover work-related illnesses or injuries suffered by civilian employees of federal agencies, including occupational diseases acquired by them.
personal injury protection (PIP)
Insurance coverage for medical expenses and other expenses related to a motor vehicle accident.
phisician of record
Provider under a workers' compensation claim who first treats the patient and assesses the level of disability.
A report filed by the physician in state workers' compensation cases when a patient's medical condition or disability changes; also known as a supplemental report.
Social Security Disability Insurance (SSDI)
The federal disability compensation program for salaried and hourly wage earners, self-employed people who pay a special tax, and widows, widowers, and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefits if alive.
Action by payer to recoup expenses for a claim it paid when another party should have been responsible for paying at least a portion of that claim.
Supplemental Security Income (SSI)
Government program that helps pay living expenses for low-income older people and those who are blind or have disabilities.
Retraining program covered by workers' compensation to prepare a patient for reentry into the workforce.
The process followed by health plans to examine claims and determine benefits.
An administrative code used to explain an adjustment on the insured's account
Classification of accounts receivable by the length of time an account is due.
A request sent to a payer for reconsideration of a claim adjudication.
Software feature that enables automatic entry of payments on a remittance advice to credit an individual's account
An account deemed uncollectible.
A term that refers to all the activities that are related to patient accounts and follow-up.
Type of billing in which patients with current balances are divided into groups to even out statement printing and mailing throughout a month, rather than mailing all statements once a month.
In a medical office, a report that summarizes the business day's charges and payments, drawn from all the patient ledgers for the day.
A payer's decision about the benefits due for a claim.
Payer process of gathering information in order to adjudicate a claim.
A payer'sreview and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider.
electronic funds transfer (EFT)
Electronic routing of funds between banks.
electronic remittance advice (ERA)
A transaction that explains a payer's payment decisions to the provider.
Equal Credit Opportunity Act (ECOA)
Law which prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because a person receives public assistance.
explanation of benefits (EOB)
Document sent by a payer to a patient that shows how the amount of a benefit was determined.
Fair Debt Collection Practices Act (FDCPA) of 1997
Laws regulating collection practices
Grouping patient billing under the insurance policyholder; the gurantor receives statements for all patients covered under the policy.
insurance aging report
A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days.
Checks written from an account that does not have adequate funds (or has "nonsufficient funds") to cover the check, and are not honored by the bank; also referred to as "bounced" or "returned" checks.
From the payer's point of view, improper or excessive payment resulting from billing errors for which the provider owes a refund.
patient aging report
A report grouping unpaid patients' bills by the length of time that they remain due, such as 30, 60, 90, or 120 days.
The record of a patient's financial transactions.
A report that shows the services provided to a patient, total payments made, total charges, adjustments, and balance due.
Money that is owed to a patient.
Comparison of two numbers to determine whether they differ.
Telephone Consumer Protection Act of 1991
Federal law that regulates consumer collections to ensure fair and ethical treatment of debtors; governs calling hours and methods.
Truth in Lending Act
Federal law requiring disclosure of finance charges and late fees for payment plans.
Money that cannot be collected from the practice's payers or patients and must be written off.
Use of a procedure code that provides a higher payment than the code for the service actually provided.
HIPAA-mandated format for claims for institutional services.
admitting diagnosis (ADX)
The patient's condition determined by a physician at admission to an inpatient facility.
The clinician primarily responsible for the care of the patient from the beginning of a hospitalization
charge master (charge ticket)
A hospital's list of the codes and charges for its services
Paper claim for hospital services; also known as the UB-04
Admitted patient's coexisting conditions that affect the length of the hospital stay or the course of treatment
Conditions an admitted patient develops after surgery or treatment that affect the length of hospital stay or the course of further treatment
diagnosis-related groups (DRGs)
A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services
The procedural coding system used to code procedures performed during hospitalization
A person admitted to a medical facility for services that require an overnight stay.
Inpatient Prospective Payment System (IPPS)
Medicare payment system for hospital services; based on diagnosis-related groups (DRGs)
master patient index (MPI)
Hospital's main patient database
Medicare-Severity DRGs (MS-DRGs)
A new type of DRG adopted by Medicare in 2008 to better reflect the different severity of illness among patients who have the same basic diagnosis
Outpatient Prospective Payment System (OPPS)
The payment system for Medicare Part B services that facilities provide on an outpatient basis
present on admission (POA)
A code used in situations when a condition existed at the time the order for inpatient admission occurs
principal diagnosis (PDX)
The condition established after study to be chiefly responsible for the admission
The procedure that is most closely related to the treatment of the principal diagnosis
Process of gathering personal and insurance information about a patient during admission to a hospital
Currently madated paper claim for hospital billing
A BCBS program that provides benefits for plan subscribers who are away from their local areas.
BlueCross BlueShield Association (BCBS)
The national licensing agency of BlueCross and BlueShield plans
A part of a standard health plan that is changed under a negotiated employer-sponsored plan; also refers to subcontracting of coverage by a health plan.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for eighteen months after termination.
Periodic verificaiton that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.
Nonemergency surgical procedure that can be scheduled in advance.
Employee Retirement Income Security Act of 1974 (ERISA)
A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.
Fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.
Federal Employees Health Benefits (FEHB) program
The health insurance program that covers employees of the federal government.
The BCBS consumer-driven health plan funding opetion that has employer and employee contributions; funds left over revert to the employer.
group health plan (GHP)
Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide health care to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group health plans.
A BCBS plan in the community where the subscriber has contracted for coverage.
A participating provider's local BCBS plan.
Fixed amount that must be met periodically by each individual of an insured/dependent group before benefits from a payer begin.
individual health plan (IHP)
Medical Insurance plan purchased by an individual, rather than through a group affiliation.
Category of enrollment in a commercial health plan that may have different elifibility requirements.
maximum benefit limit
The amount an insurer agrees to pay for an insured's covered expenss over the course of the insured person's lifetime.
monthly enrollment list
Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.
open enrollment period
Span of time during which a policy holder selects from an emplyer's offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan.
Generally, preauthorizaiton for hospital admission or outpatient procedures.
Document that modifies an insurance contract.
self-insured health plan
An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay.
Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider's contract with a plan or bought by a self-funded plan.
The payer's process for determining medical necessity - whether the review is conducted before or after the services are provided.
utilization review organization (URO)
An organizaiton hired by the payer to evaluate the medical necessity of planned procedures.
An amount of time that must pass be
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