Cbcs Study Guide 2.1 Chapter 4 - Payment Adjudication Vocabulary

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ACCOUNTS RECEIVABLE DEPARTMENT:

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THE DEPARTMENT THAT KEEPS TRACK OF WHAT THIRD PARTY PAYERS THE PROVIDER IS WAITING TO HEAR FROM AND WHAT PATIENTS ARE DUE TO MAKE A PAYMENT

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EXPLANATION OF BENEFITS (EOB):

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DESCRIBES THE SERVICES RENDERED, PAYMENT COVERED AND BENEFIT LIMITS AND DENIALS

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CHARGE DESCRIPTION MASTER (CDM)?

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INFORMATION ABOUT HEALTH CARE SERVICES THAT PATIENTS HAVE RECEIVED AND FINANCIAL TRANSACTIONS THAT HAVE TAKEN PLACE

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REVENUE CODE:

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IS A 3 DIGIT CODE THAT DESCRIBES A CLASSIFICATION OF A PRODUCT OR SERVICE PROVIDED TO THE PATIENT. (REQUIRED FOR MEDICARE PATIENTS

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CHARGE AMOUNT:

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IS THE AMOUNT THE FACILITY CHARGES FOR THE PROCEDURE OR SERVICE. THIS AMOUNT IS NOT NECESSARILY WHAT THE FACILITY WILL RECEIVE FOR THE THIRD PARTY PAYER.

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CHARGE OR SERVICE CODE:

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IS AN INTERNALLY ASSIGNED NUMBER UNIQUE TO EACH FACILITY. IT IDENTIFIES EACH PROCEDURE LISTED ON THE CHARGE. THIS CODE CAN BE USEFUL FOR TRACKING REVENUE.

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GENERAL LEDGER KEY:

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IS A 2 OR 3 DIGIT NUMBER THAT MAKES SURE THAT A LINE ITEM IS ASSIGNED TO THE GENERAL LEDGER IN THE HOSPITAL’S ACCOUNTING SYSTEM

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ACTIVITY OR STATUS DATE:

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INDICATES THE MOST RECENT ACTIVITY OF AN ITEM

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AGING REPORT:

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MEASURING OUTSTANDING BALANCES IN EACH ACCOUNT

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AGE TRIAL BALANCE:

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IN ACCOUNTING THIS TERM HAS A SPECIFIC MEANING THAT REFERS TO THE STATUS OF AN INVOICE

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MEDICARE SUMMARY NOTICE:

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DOCUMENT THAT OUTLINES THE AMOUNTS BILLED BY THE PROVIDER AND WHAT THE PATIENT MUST PAY THE PROVIDER

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ACCOUNT NUMBER:

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NUMBER THAT IDENTIFIES SPECIFIC EPISODES OF CARE, DATE OF SERVICE, OR PATIENT

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HEALTH RECORD NUMBER:

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NUMBER THE PROVIDER USES TO IDENTIFY AN INDIVIDUAL PATIENT’S RECORD

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ACTUAL CHARGE:

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REFERS TO THE AMOUNT THE PROVIDER CHARGES FOR HEALTH CARE SERVICES. (ALSO CALL THE BILLED AMOUNT)

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ALLOWABLE CHARGE:

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IS THE AMOUNT THE INSURER WILL ACTUALLY PAY(ALSO CALLED ALLOWABLE FEE, MAXIMUM FEE, MAXIMUM ALLOWABLE, USUAL REASONABLE CUSTOMARY, UCR CHARGE, OR PREVAILING RATE)

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WRITE-OFFS:

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THE DIFFERENCE BETWEEN THE PROVIDER’S ACTUAL CHARGE AND THE ALLOWABLE CHARGE

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COST SHARING:

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THE BALANCE THE POLICY HOLDER MUST PAY THE PROVIDER

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SUBSCRIBER:

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PURCHASER OF THE INSURANCE OR THE MEMBER OF GROUP FOR WHICH AN EMPLOYER OR ASSOCIATION AS PURCHASED INSURANCE

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SUBSCRIBER NUMBER:

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UNIQUE CODE USED TO IDENTIFY A SUBSCRIBER’S POLICY

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BATCH:

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A GROUP OF SUBMITTED CLAIMS

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BALANCE BILLING:

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BILLING PATIENTS FOR CHARGES IN EXCESS OF THE MEDICARE FEE SCHEDULE

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NOTICE OF EXCLUSIONS FROM MEDICARE:

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NOTIFICATION BY THE PHYSICIAN TO A PATIENT THAT A SERVICE WILL NOT BE PAID

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ADVANCE BENEFICIARY NOTICE OF NON-COVERAGE:

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FORM PROVIDED IF A PROVIDER BELIEVES THAT A SERVICE MAY BE DECLINED BECAUSE MEDICARE MIGHT CONSIDER IT UNNECESSARY

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POSTING PAYMENTS:

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ALSO CALLED RECONCILIATION AND COLLECTION, IS THE FINAL STEP IN THE REVENUE CYCLE.

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MEDICAL NECESSITY:

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THE DOCUMENTED NEED FOR A PARTICULAR MEDICAL INTERVENTION

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GROUP CODES:

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IDENTIFY THE PARTY FINANCIALLY RESPONSIBLE FOR A SPECIFIC SERVICE OR THE GENERAL CATEGORY OF PAYMENT ADJUSTMENT

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CLAIMS ADJUSTMENT REASON CODES:

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PROVIDE FINANCIAL INFORMATION ABOUT CLAIMS DECISIONS

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REMITTANCE ADVICE REMARK CODES:

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FURTHER EXPLAIN THE REASON FOR A PAYMENT ADJUSTMENT

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PROVIDER-LEVEL ADJUSTMENT REASON CODES:

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ARE NOT RELATED TO A SPECIFIC CLAIM. THESE ADJUSTMENTS ARE MADE BY THE PROVIDER’S OFFICE

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GROUP CODE (CO) CONTRACTUAL OBLIGATION:

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USED WHEN A CONTRACTUAL AGREEMENT RESULTS IN AN ADJUSTMENT. THE PROVIDER IS NOT ALLOWED TO BILL THE PATIENT FOR THE AMOUNT OF THE ADJUSTMENT

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GROUP CODE CR) CORRECTION AND RENEWAL:

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USED FOR CORRECTING A PRIOR CLAIM

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GROUP CODE (OA) OTHER ADJUSTMENT:

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USED WHEN NO OTHER CODE APPLIES TO THE ADJUSTMENT

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GROUP CODE (PR) PATIENT RESPONSIBILITY:

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USED TO INDICATE THE AMOUNT THE PATIENT OWES, TYPICALLY FOR DEDUCTIBLE AND COINSURANCE AMOUNT

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CARC CODE 1:

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DEDUCTIBLE AMOUNT

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CARC CODE 2:

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COINSURANCE AMOUNT

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CARC CODE 3:

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COPAYMENT AMOUNT

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CARC CODE 4:

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THE PROCEDURE CODE IS INCONSISTENT WITH THE MODIFIER USED OR THE REQUIRED MODIFIER IS MISSING

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CARC CODE 5:

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THE PROCEDURE CODE/BILL TYPE IS INCONSISTENT WITH THE PLACE OF SERVICE

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CARC CODE: 40:

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CHARGES DO NOT MEET QUALIFICATIONS FOR EMERGENT/URGENT CARE

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CARC CODE 96:

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NON-COVERED CHARGE

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RARC CODE M1:

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X-RAY NOT TAKEN WITHIN THE PAST 12 MONTHS OR NEAR ENOUGH TO THE TIME OF TREATMENT

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RARC CODE M2:

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NOT PAID SEPARATELY WHEN THE PATIENT IS AN INPATIENT

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RARC CODE M3:

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EQUIPMENT IS THE SAME OR SIMILAR TO EQUIPMENT ALREADY BEING USED

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RARC CODE M4:

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ALERT: THIS IS THE LAST MONTHLY INSTALLMENT FOR PIECE OF EQUIPMENT BEING USED

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RARC CODE M125:

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MISSING/INCOMPLETE/INVALID INFORMATION ON THE PERIOD OF TIME THAT THE SUPPLY/SERVICE/EQUIPMENT WILL BE NEEDED

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RARC CODE N1:

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ALERT: YOU MAY APPEAL THIS DECISION IN WRITING AFTER RECEIVING THIS NOTICE

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RARC CODE N24:

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MISSING/INCOMPLETE/INVALID ELECTRONIC FUND TRANSFER

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PLAC CODE 50 (LATE CHARGE):

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USED TO IDENTIFY LATE CLAIM FILING PENALTY OR MEDICARE LATE COST REPORT PENALTY

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PLAC CODE 51(INTEREST PENALTY CHARGE):

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USED TO IDENTIFY THE INTEREST ASSESSMENT FOR LATE FILING

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PLAC CODE 72(AUTHORIZED RETURN):

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USED TO IDENTIFY A REFUND ADJUSTMENT TO AN INSTITUTIONAL PROVIDER FROM A PREVIOUS OVERPAYMENT

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PLAC CODE 90(EARLY PAYMENT ALLOWANCE):

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USED TO INDICATE WHEN THIS HAS OCCURRED

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AFFORDABLE CARE ACT (ACA):

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SPELLS OUT HOW PATIENTS CAN APPEAL HEALTH INSURANCE DECISIONS