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26 terms

Hospital Billing Process Ch 2 Key terms

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accounts receivable (AR)
Amount of money owed to a facility by patients and payers.
adjustment
An amount (positive or negative) entered in a billing program to change an account balance.
admission
The registration process in which patients enter the facility for care
aging
The classification of accounts receivable by the amount of time they are past due.
ancillary charge
Fee for services other than room and board provided during a patient's hospitalization, such as anesthesia, pharmacy, supplies, and therapies.
appeal
A request sent to a payer for reconsideration of a claim denial or partial payment.
attending physician
The clinician primarily responsible for the care of the patient from the hospital admission through discharge or transfer.
CDM - charge description master
A hospital's list of the codes and charges for its services.
charge explode
A billing system feature that stores all charges for particular services; when a service is provided, the system automatically bills all of its component charges.
charge slip
A form that lists the typical major services a facility department provides.
compliance
Actions that satisfy official guidelines and requirements.
discharge
Release of a patient from a facility, including those who have died and those who are transferred to another facility.
DNFB - discharged/not final bill
A hospital list containing the accounts of patients who have been discharged but whose claims have not yet been transmitted to payers, used by hospitals to measure the timeliness of their billing process.
encounter form
A listing of the services, procedures, and revenue departments for collecting charges for a patient's visit; also called a charge ticket or superbill.
EOB - explanation of benefits
A document from a payer to a patient or a provider that shows how the amount of a benefit was determined.
guarantor
The person who is responsible for the payment of a patient's bill for medical services.
inpatient-only procedures
Surgical procedures which, due to their invasive nature and the need for a twenty-four-hour recovery time, Medicare has designated will only be paid for if performed on an inpatient basis.
medical necessity
Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice.
precertification
Prior authorization from a payer that must be received before elective hospital-based or outpatient surgeries are covered; also preauthorization or authorization.
professional services
The work of physicians—such as surgeons, anesthesiologists, and patients' private doctors—that is billed to patients by the physician rather than by the facility.
QIO - quality improvement organization
An organization hired by CMS to determine the medical necessity, appropriateness, and quality of patients' treatments; formerly Peer Review Organization (PRO).
referring physician
The physician who orders a patient's services.
RA - remittance advise
The document sent by a payer to a provider that itemizes the patients, claims, and explanations for payment decisions included in the attached payment.
routine charge
The total of the costs of all supplies that are customarily used to provide the service; items included in the routine charge should not be billed separately.
uncollectible account
A patient's balance that the billing department has determined cannot be collected from the debtor and is written off.
UR - utilization review
A formal review to determine the appropriateness and usage of hospital-based health care services delivered to a member of a plan; may be conducted on a prospective, concurrent, or retrospecti