CH.3&4 (Part 2 Ch. 4) Flashcards
account receivable agin report
shows the status (by date) of outstanding claims from each payer, as well as payments due to pTs.
allowed charges
the max amount the payer will reimburse for each procedure or svc, according to the pT’s policy.
ANI ASC X12N
An electronic format standard that uses a variable-length file format to process transactions for institutinal, pro, dental, and drug claims.
appeal
documented as a latter and signed by the provider, to explain why a claim should be reocnsiderd for payment.
bad debt
accounts receivable that cannot be collected by the provider or a collecton agency.
beneficiary
the person eligible to receive health care benefits.
claims adjudication
comparing a claim to payer edits and the pT’s health plan benefits to verify that required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures perfomred and svc provided are covered benefits.
claims adjustment reason codes (CARC)
reason for denial claim as reported on the remittance advice or explanation of benefits.
claims attachment
medical report substaining a medical condition.
claims management
completion, submission, and follow-up of claims for procedures and svcs provided.
claims processing
sorting claims upon submission to collect and verify information about the pT and provider.
claims submission
the transaction of claims data (electronically or manually) to payers or clearinghouses for processing
clean claim
a correctly completed standardized claim (e.g. CMS-1500 claim)
clearinghouse
agency or organization that collects, process, and distributes health cre claims after editing and validating them to ensure that they are error-free, reforming them to the payer’s specifications, and submitting them electronically to appropriate payer for further processsing to generate reimbursement to the provider.
closed claims
claims for which all processing, includes appeals, has been completed.
common data file
summary abstratc report of all recent claims filed on each pT.
coordination of benefits (COB)
provision in group health insurance plocies that prevents multiple insures from paying benefits covered by other polocies; also specifies taht coverage in a certain sequenc when more than one policy covers the claim.
covered entities
private sector health plans, managed care organizations, govt health plans, all health care cleairnghouses; and all health care providers that choose to submit or receive transactions electronically.
delinquet account
AKA: past due account
delinquent claims
claims usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due.
delinquet claim cycle
advances through various aging periods, with practices typically focusing internal recovery efforts on older delinquet accounts
denied claims
claim returned to the provider by payers due to coding erros, missing info, and pT coverage issues.
downcoding
assigned lower-level codes than documented in the record.
electronic data interchange (EDI)
computer to computer exchange of data between provider and payer.
