Cbcs Study Guide 2.1 Chapter 2 - Claims Processing Vacobulary

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MEDICARE

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FEDERALLY FUNDED HEALTH INSURANCE PROVIDED TO PEOPLE AGE 65 OR OLDER, PEOPLE YOUNGER THAN 65 WHO HAVE CERTAIN DISABILITIES, AND PEOPLE OF ALL AGES WITH END-STAGE KIDNEY DISEASE. FUNDED AND ADMINISTERED AT THE NATIONAL LEVEL.

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MEDICAID

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A GOVERNMENT BASED HEALTH INSURANCE OPTION THAT PAYS FOR MEDICAL ASSISTANCE FOR INDIVIDUALS WHO HAVE LOW INCOMES AND LIMITED FINANCIAL RESOURCES. FUNDED AT THE STATE AND NATIONAL LEVEL ADMINISTERED ON THE STATE LEVEL.

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CLAIM

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COMPLETE RECORD OF THE SERVICES PROVIDED BY TH EHEALTH CARE PROFESSIONAL, ALONG WITH APPROPRIATE INSURANCE INFORMATION

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PATIENT’S NAME

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SHOULD BE CONSISTENT ACROSS ALL DOCUMENTS

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PATIENT’S HEALTH RECORD NUMBER

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THE PROVIDER USES THIS NUMBER TO IDENTIFY THE PATIENT

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PATIENTS’ ACCOUNT NUMBER

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IDENTIFIES SPECIFIC EPISODES OF CARE, DATE OF SERVICE, OR HOSPITALIZATION

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PATIENT’S DEMOGRAPIC INFORMATION

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DATE OF BIRTH, SEX, MARITAL STATUS, ADDRESS, TELEPHONE NUMBER, RELATIONSHIP TO SUSCRIBER, AND CIRCUMSTANCES OF CONDITION.

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CIRCUMSTANCES OF CONDITION

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RELATED TO AN AUTOMOBILE ACCIDENT OR A PRE-EXISTING CONDITION

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SUSCRIBER/MEMBER/POLICY HOLDER/CERTIFICATE HOLDER/INSURED NAME

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PURCHASER OF THE INSURANCE OR THE MEMBER OF GROUP FOR WHICH AND EMPLOYER OR ASSOCIATION HAS PURCHASED INSURANCE

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SUSCRIBER/MEMBER NUMBER

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UNIQUE CODE USED TO IDENTIFY THE SUSCRIBER’S POLICY

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GROUP/PLAN NUMBER

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UNIQUE CODE USED TO IDENTIFY A SET OF BENEFITS OF ONE GROUP OF TYPE OF PLAN

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PRIOR APPROVAL NUMBER (PRE CERTIFICATION OR PREAUTHORIZATION)

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NUMBER INDICATINGTHAT THE INSURANCE COMPANYHAS BEEN NOTIFIED AND HAS APPROVED THE SERVICES BEFORE THEY ARE RENDERED

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PROVIDER NAME

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NAME OF HOSPITAL, PHYSICIAN, OR OTHER ENTITY THAT PROVIDED SERVICES

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NATIONAL PROVIDER NUMBER (NPI)

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UNIQUE 10 DIGIT CODE FOR PROVIDERS REQUIRED BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) OF 1996

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PROVIDER’S ADDRESS AND TELEPHONE NUMBER

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ADDRESS AND TELEPHONE NUMBER OF THE ENTITY THAT PROVIDED SERVICES AND WILL BE REIMBURSED BY THE CLAIM

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DATES OF SERVICE

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DATE WHEN THE SERVICE WAS PROVIDED

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DIAGNOSIS CODE

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INTERNATIONAL CLASSIFICATION OF DISEASES CODE 9TH REVISION UNTIL SEPTEMBER 2015, THEN THE U.S. WILL BE TRANSMITTING TO ICD 10TH REVISION

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PROCEDURE CODE

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INTERNATIONAL CLASSIFCATION OF DISEASES PROCEDURE CODES (ICD-9-CM VOLUME 3 OR ICD-10-PCS), CURRENT PROCEDURAL TERMINOLGY (CPT) CODE OR HEALTHCARE COMMON PROCEDURES CODING SYSTEMS (HCPCS) THAT REPRESENT THE PROCEDURE OR SERVICE RENDERED

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REVENUE CODE

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4 DIGIT CODE THAT IDENTIFIES SPECIFIC ACCOMODATION, ANCILLARY SERVICE OR BILLING CALCULATION RELATED TO THE SERVICES ON THE BILL. INDICATES THE TYPE OF SERVICE PERFORMED, WHERE THE SERVICE WAS PERFORMED, AND PROVIDES A SUMMARY OF OTHER SERVICES AND SUPPLIES USED FOR TREATMENT

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ITEMIZED CHARGES FOR SERVICES

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DETAILED LIST OF EACH SERVICE AND ITS COST

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NUMBER OF SERVICES OR DURATION OF TIME

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DETAILS RELATED TO NUMBER OF SERVICES OR LENGTH OF TIME SERVICES WAS PROVIDED

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SECONDARY OR OTHER INSURANCE INFORMATION

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ANOTHER ENTITY THAT MAY BE RESPONSIBLE TO REIMBURSE THE PROVIDER FOR THE SERVICES RENDERED, SUCH AS AUTOMOBILE INSURANCE OR WORKERS’ COMPENSATION

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TRANSMITTING CLAIMS

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SENDING REQUIRED INFORMATION TO THIRD PARTY PAYERS FOR REIMBURSEMENT

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ELECTRONICDATA INTERCHANGE

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THE TRANSFER OF ELECTRONIC INFORMATION IN A STANDARD FORMAT, SUCH AS HEALTH CLAIMS

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CORDINATION OF BENEFITS RULES

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DETERMINES WHICH INSURANCE PLAN IS PRIMARY AND WHICH IS SECONDARY

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PRIMARY INSURANCE

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PAYS FIRST, UP TO THE LIMITS OF ITS COVERAGE

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SECONDARY INSURANCE

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PAYS SECOND, PAYS WHAT THE PRIMARY INSURANCE DID NOT PAY

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CONDITIONAL PAYMENT

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MEDICARE PAYMENT THAT IS RECOVERED AFTER PRIMARY INSURANCE PAYS

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CROSS OVER CLAIM

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CLAIMS SUBMITTED BY PEOPLE COVERED BY A PRIMARY AND SECONDARY INSURANCE PLAN

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CLEAN CLAIM

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CLAIM THAT IS ACCURATE AND COMPLETE. THEY HAVE ALL THE INFORMATION NEEDED FOR PROCESSING WHICH IS DONE IN A TIMELY FASHION

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DIRTY CLAIM

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CLAIM THAT IS INACCURATE, INCOMPLETE, OR CONTIANS OTHER ERRORS

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ASSIGNMENT OF BENEFITS

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CONTRACTS IN WHICH THE PROVIDER DIRECTLY BILLS THE PAYER AND ACCEPTS THE ALLOWABLE CHARGE

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ALLLOWABLE CHARGE

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THE AMOUNT AN INSURER WILL ACCEPT AS FULL PAYMENT MINUS THE APPLICABLE COST SHARING

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MEDICARE ADMINISTRATION CONTRATOR (MAC)

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PROCESSES MEDICARE PART A & B CLAIMS FROM HOSPITALS, PHYSICIANS, AND OTHER PROVIDERS

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REMITTANCE ADVICE

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1) A NOTICE OF PAYMENTS AND ADJUSTMENTS MEDICARE CONTRACTORS SEND TO PROVIDERS, BILLERS AND SUPPLIERS AFTER THEY PROCESS A CLAIM 2)THE REPORT SENT FROM THIRD PARTY PAYER TO THE PROVIDER THAT REFLECTS ANY CHANGES MADE TO THE ORIGINAL BILIING

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EXPLANTION OF BENEFITS (EOB)

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DESCRIBES SERVICES RENDERED, PAYMENTS COVERED, BENEFIT LIMITS AND DENIALS

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REFERRING PROVIDER

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THE PHYSICIAN WHO REQUESTS THE SERVICE FOR THE PATIENT

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ORDERING PROVIDER

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A PHYSICIAN OR WHEN APPROPRIATE, A NON PHYSICIAN WHO ORDERS NON PHYSICIAN SERVICES FOR THE PATIENT?

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SUPERVISING PROVIDER

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THE PHYSICIAN MONITORING THE PATIENT’S CARE

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HEALTH MANAGEMENT ORGANIZATION (HMO)

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PLAN THAT ALLOWS PATIENTS TO ONLY GO TO PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS, OR HOSPITALS ON A LIST OF APPROVED PROVIDERS, EXCEPT IN AM EMERGENCY

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MODIFIER

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ADDITIONAL INFORMATION ABOUT TYPES OF SERVICES, AND PART OF VALID CPT OR HCPCS CODES