Scheduled maintenance: Saturday, March 6 from 3–4 PM PST
Upgrade to remove ads
Only $2.99/month

Understanding Health Insurance, Chapter 4 Terms

Terms in this set (47)

Accept assignment
The provider agrees to accept what the insurance company allows or approves as payment in full for the claim; the patient is responsible for paying any copayment and/or coinsurance amounts
Out-of-pocket payment provision
Health insurance plans may include this, which usually has limits of $1,000 or $2,000
Accounts receivable management
Assists providers in the overall collection of appropriate reimbursement for services rendered
Guarantor
Person responsible for paying the charges
Participating provider (PAR)
Contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed; not allowed to bill patients for the difference between the contracted rate and their normal fee
Nonparticipating provider (nonPAR)
Also known as an out-of-network provider; does not contract with the insurance plan, and patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses; the patient is usually expected to pay the difference between the insurance payment and the provider's fee
Primary insurance
The insurance plan responsible for paying healthcare insurance claims first
Birthday rule
States that the policyholder whose birth month and day occurs earlier in the calendar year holds the primary policy for dependent children
Encounter form
The financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter; also called a superbill in the physician's office; called a chargemaster in the hospital
Patient ledger
Known as the patient account record in a computerized system; a permanent record of all financial transactions between the patient and the practice
Manual daily accounts receivable journal
Also known as the day sheet; a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific day
Claims submission
The electronic or manual transmission of claims data to payers or clearinghouses for processing
Clearinghouse
A public or private entity that processes or facilitates the processing of nonstandard data elements (e.g., paper claim) into standard data elements (e.g., electronic claim); also convert standard transactions (e.g., electronic remittance advice) received from payers to nonstandard formats (e.g., remittance advice that looks like an explanation of benefits) so providers can read them
Value-added network (VAN)
A clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using one of these is more efficient and less expensive for providers than managing their own systems to send and receive transactions directly from numerous entities
Electronic flat file format
Also known as electronic media claim; a series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for healthcare services
Electronic data interchange (EDI)
The computer-to-computer transfer of data between providers and third-party payers (or providers and healthcare clearinghouses) in a data format agreed upon by sending and receiving parties
Covered entities
Required to use the standards when conducting any of the defined transactions covered under HIPAA
Clean claim
Contains all required data elements needed to process and pay the claim (e.g., valid diagnosis and procedure/service codes, modifiers, and so on)
Claims attachment
A set of supporting documentation or information associated with a healthcare claim or patient encounter; this information can be found in the remarks or notes fields of an electronic claim or paper-based claim forms; used for medical evaluation for payment, past payment audit or review, and quality control to ensure access to care and quality of care
Coordination of benefits (COB)
A provision in group health insurance policies intended to keep multiple insurers from paying benefits covered by other policies; it also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim
Claims processing
Involves sorting claims upon submission to collect and verify information about the patient and provider
Claims adjudication
The process in which the claim is compared 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
Noncovered benefit
Any procedure or service reported on the claim that is not included on the master benefit list
Unauthorized services
Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization
Common data file
An abstract of all recent claims filed on each patient; this process determines whether the patient is receiving concurrent care for the same condition by more than one provider, and it identifies services that are related to recent surgeries, hospitalizations, or liability coverage
Allowed charges
The maximum amount the payer will allow for each procedure or service, according to the patient's policy
Deductible
The total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits
Coinsurance
The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid
Copayment
The fixed amount the patient pays each time he or she receives healthcare services
Remittance advice
Sent to the provider, and an explanation of benefits (EOB) is mailed to the policyholder and/or patient
Electronic funds transfer (EFT)
The payers deposit funds to the provider's account electronically
Open claims
Are organized by month and insurance company and have been submitted to the payer, but processing is not complete, include those that were rejected to an error or omission (because they must be reprocessed)
Closed claims
Filed according to year and insurance company and include those for which all processing, including appeals, has been completed
Remittance advice files
Are organized according to date of service because payers often report the results of insurance claims processed on different patients for the same date of service and provider
Unassigned claims
Organized by year and are generated for providers who do not accept assignment; the file includes all unassigned claims for which the provider is not obligated to perform any follow-up work
Appeal
Documented as a letter signed by the provider explaining why a claim should be reconsidered for payment; if appropriate, include copies of medical record documentation
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
Accounts receivable
The amounts owed to a business for services or goods provided
Consumer Credit Protection Act of 1968
Also known as the Truth In Lending Act; requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions (including disclosing finance charges expressed as an annual percentage rate)
Electronic Funds Transfer Act
Established the rights, liabilities, and responsibilities of participants in electronic fund transfer systems
Equal Credit Opportunity Act
Prohibits discrimination on the 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 and Charge Card Disclosure Act
Amended the Truth In Lending Act; requires credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-ended credit and charge accounts and under other circumstances
Fair Credit Billing Act
Amended the Truth in Lending Act; requires prompt written acknowledgement of consumer billing complains and investigation of billing errors by creditors
Fair Credit Reporting Act
Protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services
Fair Debt Collection Practices Act (FDCPA)
States that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes
Past-due account
Also known as a delinquent account; one that has not been paid within a certain time frame (e.g., 120 days)
Accounts receivable aging report
This is generated when trying to determine whether a claim is delinquent; shows the status (by date) of outstanding claims from each payer, as well as payments due from patients
THIS SET IS OFTEN IN FOLDERS WITH...