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14 Cards in this Set
- Front
- Back
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Cms1500 |
Claim form uses to bill professional services: A surgeons fees for a surgery performed at an outpatient surgery center or an emergency physicians fee for professional services provides in the er. |
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UB04 |
The claim form uses to bill outpatient facility charges: surgery centers freestanding radiology clinics, laboratories and emergency rooms |
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CPT codes |
Standard codes used to designate procedures and tests in outpatient claims |
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Guarantor |
The person who is financially responsible for a medical bill |
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Preauthorization |
The process of calling the patients insurance carrier to obtain permission for them to receive prescribed procedures |
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Premium |
The cost of coverage for the insurance policy. This is typically paid on a monthly basis employees usually share in the cost if the healthcare insurance premium with their employers. |
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Exclusions |
Procedures, tests, or services that are not covered under an insurance policy |
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HMO |
A set of care guidelines patients must follow in order to receive maximum benefits. Hmos contract with physicians, physician groups, hospitals, and clinics to provide care under the terms of the HMO. HMO patients are seen to steeply discounted rates and providers have a pipeline of patients through the hmo. |
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Adjudication |
The process if checking the details of the claim against the details the third party has on the patient and his her insurance benefits. This process will also check for completeness of the claim, bundling issues for CPT codes, medical necessity, and recent claims. |
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Aging report |
A report to manage paid and unpaid claims reconciled by date. |
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Usual, customary and reasonable |
The amount paid for a medical service ins geographic area based on what providers in the area usually charge for the same or similar medical service. |
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Resource based relative value scale (RBRVS) |
The fee for service reimbursement methodology used by Medicare to determine reimbursement amounts for physician bases services |
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Capitation |
A reimbursement method where the third party payer contracts with the healthcare providers to pay a flat fee per individual enrolled in the healthcare plan. The actual service provided to the patient, few or numerous, don't affect the reimbursement to the provider. |
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Global prospective payment system |
The Medicare system used to reimburse home health services. HHPPS or home health prospective payment system |
