Revenue Cycle Flashcards
(49 cards)
Accept assignment
Provider accepts as payment in full whatever is paid in the claim by the payer (exception: copay and Coinsurance)
Accounts receivable
The amount owed to a business for services or goods provided
Accounts receivable aging report
Shows the status by date of outstanding claims from each payer, as well as payments due from patients
Accounts receivable management
Assists providers in the collection of appropriate reimbursement for services rendered; including functions such as insurance verification/ eligibility and pre authorization of services
Allowed charge
The maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
ANSI asc x12n
An electronic format that uses a variable- length file format to process transactions for institutional, professional, dental, and drug claims
Appeal
Document as a letter, signed by the provider, explaining why the claim should be reconsidered for payment
Assignment of benefits
The provider receives a reimbursement directly from the payer
Bad debt
Accounts receivable that cannot be collected by the provider or a collection agency
Beneficiary
The person eligible to receive health care benefits
Birthday rule
Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan
Case management
Development of patient care plans to coordinate and provide care for complicated cases in a cost effective manner
Charge master
Document that contains a computer generated list of procedures, services, and supplies with charges for each; charge master data are entered in the facility’s patient accounting system, and charges are automatically posted to the patient’s bill (ub-04)
Charge master maintenance
Process of updating and revising key elements of the charge master to ensure accurate reimbursement
Claims adjudication
Comparing a claim 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
Claims adjustment reason code
Reason for denied claim as reported on the remittance advice or explanation of benefits
Claims attachment
Medical report substantiating a medical condition
Claims denial
Unpaid claim returned by third party payer because of beneficiary identification errors, coding errors, diagnosis that does not support medical necessity of procedure/ service, duplicate claims, global days of surgery e/m coverage issue, NCCI edits, and other patient coverage issues
Claims processing
Sorting claims upon submission to collect and verify information about the patient and provider
Claims rejection
Unpaid claims returned by third party payers because it fails to meet certain data requirements, such as missing data
Claims submission
The transmission of claims data to payers from clearinghouses for processing
Clean claim
A correctly completed standardized claim
Clearinghouse
Agency or organization that collects, processes, and distributes health care claims after editing and validating them to ensure that they are error free , reformatting them to the payer’s specifications, and submitting them electronically to the appropriate payer for further processing to generate reimbursement to the provider
Closed claim
Claims for which all processing, including appeals, has been completed
