Chpt 4

Front 1

Patients can be billed for non-covered procedures but NOT

Back 1

UNAUTHORIZED SERVICES

Front 2

GUARANTOR

Back 2

PERSON RESPONSIBLE FOR PAYING THE CHARGES

Front 3

THE DEVELOPMENT OF AN INSURANCE CLAIM BEGINS WHEN

Back 3

THE PROVIDER'S OFFICE COMPLETES AND SUBMITS THE CMS-1500 FORM

Front 4

THE CHECK-IN PROCEDURE FOR A PATIENT WHO IS NEW TO THE PROVIDER'S OFFICE IS

Back 4

MORE EXRENSICE THAN FOR A RETURNING PATIENT

Front 5

CLAIMS ATTACHMENT

Back 5

SUPPORTING DOCUMENTATION OR INFORMATION THAT IS ASSOCIATED WITH A HEALTHCARE CLAIM OR PATIENT ENCOUNTER

Front 6

IT IS NECESSARY TO SUBMIT A CLAIMS ATTACHMENT WHEN USING

Back 6

AN UNLISTED CPT CODE

Front 7

ACCEPT ASSIGNMENT

Back 7

THE PROVIDER AGREES TO ACCEPT WHAT INSURANCE ALLOWS OR APPROVES AS PAUMENT IN FULL FOR THE CLAIM

Front 8

CMS-1500 FORM REQUIRES RESPONSES TO STANDARD QUESTIONS PERTAINING TO:

Back 8

AUTO ACCIDENT; SECONDARY INSURANCE AND EMPLOYMENT (AMONG OTHER THNGS)

Front 9

CLEAN CLAIM

Back 9

CONTAINS ALL REQUIRED DATA ELEMENTS NEEDED TO PROCESS AND PAY THE CLAIM

Front 10

TO PROCESS A CLAIM YOU NEED TO KNOW

Back 10

THE NAME AND PHONE NUMBER OF THE 3RD PARY PAYER AND THE NAME OF THE POLICYHOLDER (AMONG OTHER THINGS)

Front 11

SOF

Back 11

SIGNATURE ON FILE

Front 12

CMS-1500 FOR IS USED TO

Back 12

REPORT PROFESSIONAL AND TECHNICAL SERVICES

Front 13

IF A PAYER MARKS A CLAIMS WITH "PENDING" STATUS, THE PROVIDER CAN RESPOND BY

Back 13

CORRECTING ERRORS AND OMISSIONS ON THE CLAIMS AND RESUBMIT FOR REONSIDERATION

Front 14

APPEAL

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A LETTER SIGNED BY THE PROVIDER EXPLAINING WHY A CLAIM SHOULD BE RECONDIFERED FOR PAYMENT

Front 15

PAR

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PARTICIPATING PROVIDER

Front 16

PARTICIPATING PROVIDER

Back 16

CONTRACTS WITH A HEALTH INSURANCE PLAN AND ACCEPTS WHATEVER THE PLAN PAYS FOR PROCEDURES AND SERVICES PERFORMED

Front 17

THE PAR IS NOT ALLOWED TO

Back 17

BILL THE PATIENT'S FOR THE DIFFERENCE (CALLED BALANCE BILLING)

Front 18

SIGNATURE ON FILE

Back 18

THIS CAN BE SUMITTED FOR THE PATIENT'S SIGNATURE AS LONG AS THE PATIENT'S SIGNATURE IS ON FILE IN THE OFFICE

Front 19

ENCOUNTER FORM

Back 19

THE FINANCIAL RECORD SOURCE DOCUMENT USED BY HEALTHCARE PROVIDERS TO RECORD TREATED DIAGNOSES AND SERVICES RENDERED TO THE PATIENT DURING THE ENCOUNTER

Front 20

CLEARINGHOUSES PROCESS CLAIMS THAT ARE

Back 20

FILED IN A "FLAT" FORMAT AND CONVERTED TO A "STANDARD" FORMAT

Front 21

THE BIRTHDAY RULE

Back 21

PARENT WHOSE BORTH MONTH AND DAY IS EARLIEST IN THE YEAR HOLDS THE PRIMARY POLICY FOR DEPENDENT CHILDREN

Front 22

WORKER'S COMPENSATION IS ALWAYS CONDIDERED TO BE

Back 22

PRIMARY TO THE INSURANCE PLAN

Front 23

THE PATIENT ACCOUNT RECORD IS

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A PERMANENT RECORD OF ALL FINANCIAL TRANACTION BETWEEN THE PATIENT AND THE PRACTICE

Front 24

COPAYMENTS

Back 24

ARE SUPPOSED TO BE PAID AT THE TIME OF VISIT

Front 25

THE BIRTHDAY RULE IS A POLICY DETERMINATION FOR

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COVERED CHILDREN

Front 26

WHEN CHILDREN ARE COVERED BY THE INSURANCE POLICY OF BOTH PARENTS, THE BIRTHDAY RULE SAYS THE PARENT WHOSE BIRTH MONTH AND DAY OCCUR EARLIER IN THE CALENDAR YEAR

Back 26

HOLDS THE PRIMARY POLICY

Front 27

DAY SHEET

Back 27

CHRONOLOGICAL SUMMARY OF ALL TRANSACTIONS POSTED ON A SPECIFIC DAY

Front 28

BEFORE SCHEDULING AN APPOINTMENT WITH A SPECIALIST, A MANAGED CARE PATIENT MUST OBTAIN A REFERRAL FROM THEIR

Back 28

PCP OR CASE MANAGER

Front 29

GENDER RULE

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STATES THE FATHER'S PLAN IS ALWATS PRIMARY WHEN THE CHILD IS COVERED BY BOTH PARENTS

Front 30

PRIMARY INSURANCE IS

Back 30

THE INSURANCE PLAN RESPONSIBLE FOR PAYING HEALTH CARE INSURANCE CLAIMS FIRST

Front 31

SOAP NOTES ARE USED IN THE PROVIDER'S OFFICE TO

Back 31

DOCUMENT PATIENT VISITS

Front 32

WHEN A PATIENT ARRIVES AT THE DOCTOR'S OFFICE, THE HEALTH INFORMATION SPECIALIST SHOULD

Back 32

HAVE THE PATIENT COMPLETE A PATIENT REGISTRATION FORM

Front 33

PATIENT ACCOUNT RECORD IS

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A COMPUTERIZED RECORD OF ALL FINANCIAL TRANSACTIONS BETWEEN PATIENTS AND THE PRACTICE

Front 34

GENERATE A SEPARATE FINANCIAL RECORD AND MEDICAL RECORD FOR

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EACH PATIENT TO MAINTAIN EACH TYPE OF INFORMATION

Front 35

CLAIM ATTACHMENT

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SUPPORTING DOCUMENTATION ASSOCIATED WITH A HEALTHCARE CLAIM FOR PATIENT ENCOUNTER

Front 36

THE PATIENT ACCOUNT RECORD IS ALSO CALLED

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THE PATIENT LEDGER

Front 37

ELECTRONIC FLAT FILE

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CLEARINGHOUSE CLAIMS PRCOESSING FORMAT

Front 38

THE SUPERBILL AND ENCOUNTER FORM ARE THE FINANCIAL RECORD SOURCE DOCUMENTS USED BY

Back 38

HEALTHCARE PROVDIERS TO RECORD SERVICES AND DIAGNOSES RENDERED DURING THE VISIT

Front 39

CHRAGEMASTER

Back 39

HOSPITAL FINANCIAL RECORD SOURCE DOCUMENT

Front 40

NONPAR IS

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A PHYSICIAN WHO IS NOT CONRACTED WITH AN INSURANCE COMPANY

Front 41

MODIFIER

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REPORTED ON CLAIMS TO PROVIDE CLARIFICATIONS ABOUT PROCEDURES AND SERVICES PERFORMED

Front 42

VAN

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VALUE-ADDED NETWORK

Front 43

VALUE-ADDED NETWORK

Back 43

CLEARINGHOUSE THAT INVOLVES VENDORS LIKE BANKS, IN THE PROCESSING OF CLAIMS

Front 44

SOME EXAMPLES OF COVERED ENTITIES ARE

Back 44

· PRIVATE SECTOR HEALTH PLANS

· MANAGED CARE

ORGANIZATIONS

· ERISA- COVERED BENEFIT PLANS· GOVERNMENT HEALTH PLANS

· HEALTHCARE CLEARINGHOUSES

· PROVIDERS THAT SUBMIT OR RECEIVE CLAIMSELECTRONICALLY

Front 45

PRIMARY INSURANCE PAYS

Back 45

FIRST AND SECONDARY PAYS AFTER