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166 Cards in this Set

  • Front
  • Back
Adjudication
Series of steps that determine whether a claim should be paid
Clearinghouse
An organization that receives claims from a provider, checks and prepares them for processing, and transmits them to insurance carriers in a standardized format
Documentation
A record of healthcare encounters between the physician and the patient, created by the provider
Electronic health record (EHR)
A computerized lifelong healthcare record for an individual that incorporates data from all providers who treat the individual
Encounter form
A list of the procedures and diagnoses for a patient's visit
Health information exchange (HIE)
A network that enables the sharing of health related information among provider organizations according to nationally recognized standards
Meaningful use
The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system
Medical documentation and billing cycle
A ten-step process that results in timely payment for medical services
Patient-centered medical home (PCMH)
A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement
Personal health record (PHR)
A comprehensive record of health information that is created and maintained by an individual over time
Practice management program (PMP)
Health information technology applications that facilitate the day-to-day financial operations of a medical practice
Protected health information (PHI)
Information about a patient's health or payment for healthcare that can be used to identify the person
Remittance advice (RA)
A document that lists the amount that has been paid on each claim as well as the reasons for nonpayment or partial payment
Revenue cycle management (RCM)
The process of managing the activities associated with a patient encounter to ensure that the provider receives full payment for services
Access rights
An option that determines which areas of the program a user can access and whether the user can only view data or has rights to enter or edit data
Auto Log Off
A feature that automatically logs a user out of the program after a specified number of minutes of inactivity
Backup data
A copy of data files made at a specific point in time that can be used to restore data to the system
Database
A collection of related pieces of information
MMDDCCYY format
The way dates must be entered in Medisoft
Medisoft program date
The date recorded in Medisoft when a transaction is entered
Packing data
The deletion of vacant slots from the database
Purging data
The process of deleting files of patients who are no longer seen by a provider in a practice
Rebuilding indexes
A process that checks and verifies data and corrects any internal problems with the data
Recalculating balances
The process of updating balances to reflect the most recent changes made to the data
Restoring data
The process of retrieving data from backup storage devices
Chart number
A unique number that identifies a patient
Office Hours break
A block of time when a physician is unavailable for appointments with patients
Office Hours calendar
An interactive calendar that is used to select or change dates in Office Hours
Office Hours patient information
The area of Office Hours window that displays information about the patient who is selected in the provider's daily schedule
Provider's daily schedule
A listing of time slots for a particular day for a specific provider that corresponds to the date selected in the calendar
Provider selection box
A selection box that determines which provider's schedule is displayed in the provider's daily schedule
Recall list
A list of patients who need to be contacted for future appointments
Established patient
A patient who has been seen by a provider in the practice in the same specialty or subspecialty within three years
Guarantor
An individual who may not be a patient of the practice but who is financially responsible for a patient account
New patient
A patient who has not received services from the same provider or a provider of the same specialty or subspecialty within the same practice for a period of three years
Capitated plan
An insurance plan in which payments are made to primary care providers whether patients visit the office or not
Case
A grouping of transactions organized around a common element
Crossover claims
Claims that are processed by Medicare and then transferred to Medicaid, or to a payer that provides supplemental insurance benefits to Medicare beneficiaries
Primary insurance carrier
The insurance company that receives claims before they are submitted to any payer
Progress notes
Physician's notes about a patient's condition and diagnosis
Referring provider
A physician who recommends that a patient make an appointment with a particular doctor
Sponsor
The active-duty service member on the TRICARE government insurance program
Adjustments
Portion of the bill that the insurance company will write off as non-allowable and cannot be collected
Charges
The amounts billed by a provider for particular services
MultiLink Codes
Groups of procedure code entries that are related to a single activity
NSF check
A payment not honored by a bank because the account it was written on does not have sufficient funds to cover the check
Payments
Monies paid to a medical practice by patients and insurance carriers
Walkout receipt
A receipt given to the patient after a payment is made that lists the procedures, diagnosis, charges, and payment
Capitation
Private or government organization that insures or pays for healthcare
Capitation
A fixed amount that is paid to a provider to provide medically necessary services to patients
Clean claims
Healthcare claims with all the correct information necessary for payer processing
CMS-1500
The mandated paper insurance claim form
Point-of-service (POS) plan
A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network
Preferred provider organization (PPO)
A network of healthcare providers who agree to provide services to plan members at a discounted fee
x12 837 Health Care Claim or Equivalent Encounter Information (837P)
The electronic form of the claim used by physician offices to bill for services
Autoposting
The automatic posting of data in the remittance advice yo a practice management program
Capitation payments
Payments made to physicians on a regular basis (such as monthly) fir providing services to patients in a managed care insurance plan
Cycle billing
A type of billing in which patients are divided into groups and statement printing and mailing are staggered throughout the month
Electronic funds transfer (EFT)
The electronic movement of monies from one bank account to another
Electronic remittance advice (ERA)
An electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier
Fee schedule
A document that specifies the amount the provider will be paid for each procedure
Once-a-month billing
A type of billing in which statements are mailed to all patients at the same time each month
Coinsurance
Percentage of charges that an insured must pay for healthcare services after payment of the deductible amount
Patient statement
A list of the amount of money s patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
Payment schedule
A document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement
Remainder statements
Statements that list only those charges that are not paid in full after all insurance carrier payments have been received
Standard statements
Statement that shows all charges regardless of whether the insurance has paid on the transactions
Accounts receivable
Monies that are coming into the practice
Aging report
A report that lists the amount of money owed the practice, organized by the length of time the money has been owed
Day sheet
A report that provides information on practice activities for a twenty-four hour period
Insurance aging report
A report that lists how long a payer has taken to respond to insurance claims
Patient aging report
A report that lists a patient's balance by age, date, and the amount of the last payment
Patient day sheet
A summary of the patient activity on a given day
Copayment
A small fee paid by the patient at the time of an office visit
Patient ledger
A report that lists the financial activity in each patient's account, including charges, payments, and adjustments
Payment day sheet
A report that lists payments received on a given day, organized by provider
Practice analysis report
A report that analyzes the revenue of a practice for a specified period of time, usually a month or year
Procedure day sheet
A report that lists the procedures performed on a given day, listed in numerical order
Collection agency
An outside firm hired to collect on delinquent accounts
Collection list
A tool for tracking activities that need to be completed as part of the collection process
Collection tracer report
A tool for tracking collection letters that were sent
Payment plan
An agreement between a patient and a practice in which the patient agrees to make regular monthly payments over a specified period of time
Prompt payment laws
Legislation that mandates a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer
Tickler
A reminder to follow up on an account
Deductible
The amount a policyholder must spend on medical services before benefits begin
Timely filing
A time period within which claims must be filed with an insurance carrier
Uncollectible amount
An account that does not respond to collection efforts and is written off the practice's expected accounts receivable
Write-off
A balance that is removed from a patient's account
Health maintenance organization (HMO)
A type of managed care system in which providers are paid fixed rates at regular intervals
High-deductible health plan with savings option (HDHP/SO)
A type of managed care insurance in which a high-deductible plan is combined with s pre-tax savings account to cover out-of-pocket medical expenses
Indemnity plan
An insurance plan in which policyholders are reimbursed for healthcare costs
Managed care
A type if insurance in which the carrier is responsible for the financing and delivery of healthcare
Medical necessity
Healthcare services that are reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care
Payer
Private or government organization that insures or psys for heslthcare
CMS-1500
The mandated paper insurance claim form
Point-of-service (POS) plan
A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network
Copayment
A fixed amount paid by the patient at the time of an office visit
x12 837 Health Care Claim or Equivalent Encounter Information (837P)
The electronic form of the claim used by physician offices to bill for services
Autoposting
The automatic posting of data in the remittance advice yo a practice management program
High-deductible health plan with savings option (HDHP/SO)
A type of managed care insurance in which a high-deductible plan is combined with a pre-tax savings account to cover out-of-pocket medical expenses
Cycle billing
A type of billing in which patients are divided into groups and statement printing and mailing are staggered throughout the month
Managed care
A type of insurance in which the carrier is responsible for the financing and delivery of healthcare
Electronic remittance advice (ERA)
An electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier
Payer
Private or government organization that insures or pays for healthcare
Once-a-month billing
A type of billing in which statements are mailed to all patients at the same time each month
Coinsurance
Percentage of charges that an insured must pay for healthcare services after payment of the deductible amount
Patient statement
A list of the amount of money s patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
Autoposting
The automatic posting of data in the remittance advice to a practice management program
Capitation payments
Payments made to physicians on a regular basis (such as monthly) for providing services to patients in a managed care insurance plan
Standard statements
Statement that shows all charges regardless of whether the insurance has paid on the transactions
Accounts receivable
Monies that are coming into the practice
Aging report
A report that lists the amount of money owed the practice, organized by the length of time the money has been owed
Day sheet
A report that provides information on practice activities for a twenty-four hour period
Insurance aging report
A report that lists how long a payer has taken to respond to insurance claims
Patient statement
A list of the amount of money a patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
Payment schedule
A document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement
Copayment
A small fee paid by the patient at the time of an office visit
Patient ledger
A report that lists the financial activity in each patient's account, including charges, payments, and adjustments
Payment day sheet
A report that lists payments received on a given day, organized by provider
Practice analysis report
A report that analyzes the revenue of a practice for a specified period of time, usually a month or year
Procedure day sheet
A report that lists the procedures performed on a given day, listed in numerical order
Collection agency
An outside firm hired to collect on delinquent accounts
Collection list
A tool for tracking activities that need to be completed as part of the collection process
Collection tracer report
A tool for tracking collection letters that were sent
Payment plan
An agreement between a patient and a practice in which the patient agrees to make regular monthly payments over a specified period of time
Prompt payment laws
Legislation that mandates a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer
Tickler
A reminder to follow up on an account
Deductible
The amount a policyholder must spend on medical services before benefits begin
Timely filing
A time period within which claims must be filed with an insurance carrier
Uncollectible amount
An account that does not respond to collection efforts and is written off the practice's expected accounts receivable
Write-off
A balance that is removed from a patient's account
Health maintenance organization (HMO)
A type of managed care system in which providers are paid fixed rates at regular intervals
High-deductible health plan with savings option (HDHP/SO)
A type of managed care insurance in which a high-deductible plan is combined with s pre-tax savings account to cover out-of-pocket medical expenses
Indemnity plan
An insurance plan in which policyholders are reimbursed for healthcare costs
Managed care
A type if insurance in which the carrier is responsible for the financing and delivery of healthcare
Medical necessity
Healthcare services that are reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care
Payer
Private or government organization that insures or psys for heslthcare
Precertification
Calling the insurance company to ensure the procedure is a covered expense
Precertification
Calling the insurance company to ensure the procedure is a covered expense
Preauthorization
Calling the insurance company to see if the procedure is medically necessary
Precertification
Calling the insurance company to ensure the procedure is a covered expense
Preauthorization
Calling the insurance company to see if the procedure is medically necessary
Predetermination
Calling the insurance company to see the dollar amount authorized as the allowable amount
Coordination of benefits
Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
Coordination of benefits
Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
Birth day law rule
Only deals with dependent children; determined by which parent was born first within calendar year (M & D)
Coordination of benefits
Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
Birth day law rule
Only deals with dependent children; determined by which parent was born first within calendar year (M & D)
EOB
Explanation of benefits consists of patient's name & info (SS#, BD), provider info (Dr. name), date of service, procedure code, amount billed, amount allowed, amount applied to deductible, copay/coinsurance, amount paid to provider, reason code
Medicaid
State funded program for indigent
Medicaid
State funded program for indigent
Medicare
State/federally funded program acquired if one is handicapped, age 65 or older, suffers End Stage Renal Disease, or Black Lung Disease
Allowable
Maximum amount the insurance will pay for a charge
Allowable
Maximum amount the insurance will pay for a charge
Copayment
Fixed amount a patient pays at each visit
Allowable
Maximum amount the insurance will pay for a charge
Copayment
Fixed amount a patient pays at each visit
Coinsurance
The percentage of the allowable to be paid by the patient
Deductible
The out-of-pocket expense to be paid by the patient before the insurance will pay
Premium
The amount one pays to have insurance
Confidentiality
Ensuring the privacy of a patient's medical records and other health information by safeguarding with limits on the use and access of this information without patient authorization
CPT
Current Procedural Terminology; all the procedures that we do to the people
CPT
Current Procedural Terminology; all the procedures that we do to the people
ICD-9-CM
International Classification of Disease - 9th Edition; what is wrong with the person
Assignment of benefits
Giving doctor permission to treat and giving insurance company permission to pay doctor
Encounter form
List of all diagnoses and procedure codes; superbill, charge slip, routing slip