Flashcards in Billing/Coding Terms Deck (46)
Money Owed BY the business
Income or money owed TO the business
The Patient, Caregiver, power of attorney, or other entity responsible for the payment of the healthcare bill
A group that takes non-standard medical billing software formats and translate them into the standard EDI formats for submission to insurance payers
American Medical Association.
This organization manages and maintains the yearly CPT code list
Centers for Medicare and Medicaid services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program.
CMS works to make sure that the beneficiaries in these programs are able to get high quality healthcare
Someone who provides medical services, such as doctors, hospitals, or labs.
CMS – 1450
UB – 04. Uniform Bill, formally known as UB – 92,
used for institutional billing also known as hospital visits.
CMS – 1500
The standard claim form used my health plans on which to consider payment to the medical provider.
Date of service (DOS)
The beginning and end dates of the health related service you received from the provider.
If the claim is for a doctor visit, the beginning and end dates will be the same.
Agreed amount of the charges for medical services that patients or guarantors must pay.
Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10, 80/20, or 70/30 etc.
For example- the insurance carrier pays 80% and the patient pays 20%
How much cost sharing one must pay for medical services, often before insurance company starts to pay. The amount patient must pay before insurance coverage begins.
For example, the patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctors visits or prescriptions to reach the deductible.
One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit.
Typically includes several commonly use ICD 10 diagnosis and CPT procedural codes.
One of the most frequently used medical billing terms
Physical characteristics of a patient such as age, sex, address etc.
Necessary for filing a claim
Identifies the individual who holds the insurance policy for coverage.
Also known as the insured person, insured, or policyholder.
Assignment of benefits
The patient or guardian sign the assignment of benefits form so that the medical provider will receive the insurance payment directly.
If this form is not signed, the patient or guardian will receive the insurance payment.
And insurance plan which a provider signed a contract to participate in.
The provider agrees to except a discounted rate for procedures.
Medical bill that is sent to an insurance company for processing.
In patient (IP)
Patient who stay overnight in the hospital
Patient who does not need to stay overnight in the hospital.
Outpatient services include labs, x-rays and some surgeries.
Actual charge or charge
Amount of money a doctor for supplier charges for a certain medical service or supply.
The amount is often more than the insurance plan approves.
A complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.
A claim that does not have to be investigated by insurance companies before they process it.
Medical claim submitted after the time frame allowed by the insurance payer.
Claims submitted after this date are denied.
The amount of the billed charge the insurance company deems is payable.
The amount of charges a provider for hospital agrees to write off and not charge the patient per the contract terms with the insurance company.
Electronic remittance advice (ERA)
This is an electronic version of an insurance EOB that provides details of insurance payments.
Explanation of benefits (EOB)
The notice one receipt from their insurance company after getting medical services from a doctor or hospital.
It explains what was billed, the payment amount approved by the insurance, the amount paid and what is still left to pay.
The amount the patient is responsible for paying that is not covered by the insurance plan.