Computer Software Applications Chapter 11

Front 1

Electronic remittance advice (ERA)

Back 1

Electronic document that list patient dates of service charges and the amounts paid or denied by the insurance carrier

Front 2

X 12 835 electronic remittance advice(835)

Back 2

Electronic transaction for payment explanation

Front 3

Claim control number

Back 3

Unique number assigned to a claim by the sender. also .known as ID number. Maximum of 20 characters

Front 4

Remittance advice (RA)

Back 4

Document describing a payment resulting from a claim adjunction

Front 5

Auto posting

Back 5

Software feature enabling automatic entry of payments for a remittance advice

Front 6

Claim adjustment group code(CAGC)

Back 6

Used on an RA/EOB to indicate the general type of reason code for an adjustment

Front 7

Claim adjustment reason code(CARC)

Back 7

Used in anRA/EOB to explain why a payment does not match the amount billed

Front 8

remittance advice remark code(RARC)

Back 8

Cold that explains a payers payment decision

Front 9

Patient responsibility (PR)

Back 9

Appears next to an amount that can be billed to the patient or insurance

Front 10

Contractual obligations (CO)

Back 10

Appears when a contract between the payer and the provider results in adjustment

Front 11

Corrections and reversals(CR)

Back 11

Appears to correct a previous claim

Front 12

Other adjustments (OA)

Back 12

Used only when either PR or CO a prize or when another insurance is primary

Front 13

Payer initiated reduction(PI)

Back 13

Appears when the payer thinks that the patient is not responsible for the charge but there's no contract between the payer and the provider that states this

Front 14

Electronic funds transfer (EFT)

Back 14

Electronic routing of funds between banks

Front 15

Capitation payment

Back 15

Payments made to position on a required basis for providing service to patients in a managed care plan

Front 16

appeal

Back 16

request for reconsideration of a claim adjustment

Front 17

claimant

Back 17

person or entity exercising the right to receive benefits

Front 18

appellant

Back 18

person who appeals a claim decision

Front 19

post payment audit

Back 19

review conducted after a claim is adjudicated

Front 20

recovery audit contractor (RAC)

Back 20

entity that audits medicare claims to determine where there are opportunities to recover incorrect payments from previously paid but non covered services, erroneous coding, and duplicate services

Front 21

overpayment

Back 21

improper or excessive amount received by provider from payer

Front 22

takeback

Back 22

balance that a provider owes a payer following a post payment audit

Front 23

patient statement

Back 23

list of the amount of money a patient owes. The procedures performed and the dates the procedure was performed

Front 24

explanation of benefits (EOB)

Back 24

document showing how the amount of a benefit was determined

Front 25

Standard elements

Back 25

statement that shows all charges regardless of whether the insurance carrier has paid on the transactions

Front 26

remainder statements

Back 26

statements that list only charges that are not paid in full after all insurance carrier payments have been received