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cimo 1&2

Terms in this set (51)

accounting cycle
the flow of financial transactions in a business
accounts receivable (AR)
monies that are flowing into a business
adjudication
series of steps that determine whether a claim should be paid
billing cycle
regular schedule of sending statements to patients
capitation
advance payment to a provider that covers each plan member's halth care services for a certain period of time
coding
the process of assigning standardized codes to diagnoses and procedures
coinsurance
part of charges that an insured person must pay for health care services after payment of the deductible amount
consumer-driven health plan (CDHP)
type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit
copayment
a small fixed fee paid by the patient at the time of an office visit
diagnosis
physician's opinion of the nature of the patient's illness or injury
diagnosis code
a standardized value that represents a patient's illness, signs, and symptoms
encounter form
a list of the procedures and charges for a patient's visit
explanation of benefits (EOB)
paper document from a payer that shows how the amount of a benefit was determined
fee-for-service
health plan that repays the policyholder for covered medical expenses
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
health plan
a plan, program, or organization that provides health benefits
managed care
a type of insurance in which the carrier is responsible for both the financing and the delivery of health care
medical coder
a person who analyzes and codes patient diagnoses, procedures, and symptoms
medical necessity
treatment provided by a physician to a patient for the pupose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice
modifier
a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service
patient information form
form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim
payer
private or government organization that insures or pays for health care on the behalf of beneficiaries
policyholder
a person who buys an insurance plan; the insured
practice management program (PMP)
a software program that automates many of the administrative and financial tasks required to run a medical practice
preferred provider organization (PPO)
managed care network of health care providers who agree to perform services for plan members at discounted fees
premium
the periodic amount of money the insured pays to a health plan for insurance coverage
procedure
medical treatment provided by a physician or other health care provider
procedure code
a code that identifies a medical service
remittance advice (RA)
an explanation of benefits transmitted electronically by a payer to a provider
statement
a list of all services performed for a patient, along with the charges for each service
administrative safeguards
administrative policies and procedures designed to protect electronic health information outlined by the HIPAA Security Rule
audit/edit report
a report from a clearinghouse that lists errors to be corrected before a claim can be submitted to the payer
audit trail
a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed
autoposting
an automated process for entering information on a remittance advice (RA) into a computer
clearinghouse
a service company that receives electronic or paper claims from the provider, checks and prepares them for processing, and transmits them in HIPAA-complaint format to the correct carriers
CMS-1500 (08/05)
the mandated paper claim form that can be used in some practices of less than 10 fulltime employees
electronic data interchange (EDI)
the exchange of routine business transactions from one computer to another using publicly available communications protocols
electronic funds transfer (EFT)
a system that transfers money electronically
electronic medical record (EMR)
electronic collection and management of health data
electronic prescribing
the use of computers and handheld devices to write and transmit prescriptions to a pharmacy in a secure digital format
HIPAA (Health Insurance Portability and Accountability Act of 1996
federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information
HIPAA Electronic Transaction and Code Sets standards
regulations requiring electronic transactions such as claim transmission to use standardized formats
HIPAA Privacy Rule
regulations for protecting individually identifiable information about a patient's past, present, or future physical and mental health and payment for health care that is created or received by a health care provider
HIPAA Security Rule
regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information
information technology (IT)
development, management, and support of computer-based hardware/software systems
National Provider Identifier (NPI)
a standard identifier for all health care providers consisting of ten numbers
physical safeguards
mechanisms required to protect electonic systems, equipment, and data from threats, environmental hazards, and unauthorized intrusion
protected health information (PHI)
information about a patient's past, present, or future physical or mental health or payment for health care that can be used to identify the person
technical safeguards
automated processes used to protect data and control access to data
walkout statement
a document listing charges and payments that is given to a patient after an office visit
X12-837 Health Care Claim (837P)
HIPAA standard format for electronic transmission of a professional claim from a provider to a health plan
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