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24 terms

Chapter 4: Processing an Insurance Claim

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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.