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20 Cards in this Set

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  • Back
professional association that represents professionals dedicated to the effective management of health insurance claims; its membership includes professional electronic billers who work for providers as well as well as professional claims assistance professionals who work for patients.
Alliance of Claims Assistance
offers 4 certification exams for coders
1.Certified Professional Coder Apprentice (CPC-A)
2.Certified Professional Coder-Hospital Apprentice(CPC-HA)
3.Certified Professional Coder (CPC)
4.Certified Professional Coder-Hospital
American Academy of Professional Coders

1. Certified Professional Coder-
Apprentice (CPC-A)
2. Certified Professional Coder-
Hospital Apprentice (CPC-HA)
3. Certified Professional Coder (CPC)
4. Certified Professional Coder (CPC-H)
American Academy of Professional Coders
(AAPC):established to provide national certification and credential-ing process,
and to support nat'l and local membership by providing educ. prods. and opportunities to network, and to increase and promote nat'l recognition & awareness of professional coding.
Professional association that represents more than 40,000 health information management professionals who work throughout the health care industry.
American Health Information Management
An administrative agency within the Federal Dept. of Health and Human Services.

(formally known as HCFA-Health Care Financing Services)
Centers for Medicare and Medicaid Svcs.

The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim.
Published by the American Medical Association and includes five-digit numeric codes and descriptors for procedures and servoes performed by providers (e.g., 99203 identifies a detailed office visit for a new patient)
Current Procedural Terminology (CPT)
Sending data in a standardized machine-readable format to an insurance company via disk, telephone, or cable.
electronic claims processing
The mutual exchange of data between provider and payer.
electronic data interchange (EDI)
The priciple of right or good conduct; rules that govern the conduct of members of a profession.
A report that details the results of processing a claim (e.g., payer reimburses prover $80.00 on a submitted charge of $100.00)
explanation of benefits (EOB)
A physician or other health care practioner (ex: physician's assistant)
health care provider
The coding system that that consists of CPT, national codes (level II), and local codes (level III),;local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.
Healthcare Common Procedure Coding Sys.

Documentation submitted to an insurance plan requesting reimbursement for health care services provided (ex.: CMS-1500 and UB-92)
health insurance claim
The patient is not responsible for what the insurance plan denies.
hold harmless clause
The coding system used to report diagnoses and reasons for encounters on physician office claims
International Classification of Diseases
9th Revision-Clinical Modifications
developed by local insurance companies and include five-digit alphanumeric codes for procedures, services, and supplies that are also not classified in CPT
local codes
(level III codes)
involves linking every procedure or service reported to the insurance company to a condition that justifies the necessity for performing that procedure or service.
medical necessity
commonly referred to as HCPCS codes, which include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT
ex: J codes are used to assign drugs administered
National Codes (level II codes)
prior approval
Prior Authorization