Insurance Claims Processing Chapter 4

Front 1

Guarantor

Back 1

Person responsible for paying the charges

Front 2

CMS-1500 Form

Back 2

Requires responses to standard questions pertaining to: auto accident; secondary insurance and employment (among other things) is used to report professional and technical services.

Front 3

Claims attachment

Back 3

Supporting documentation or information that is associated with a healthcare claim or patient encounter.

Front 4

Accept Assignment

Back 4

The provider agrees to accept what insurance allows or approves as payment in full for the claim.

Front 5

Clean Claim

Back 5

Contains all required data elements needed to process and pay the claim

Front 6

Signature on File (SOF)

Back 6

This can be submitted for the patient's signature as long as the patient's signature in on file in the office.

Front 7

Appeal

Back 7

A letter signed by the provider explaining why a claim should be reconsidered for payment.

Front 8

Participating Provider (PAR)

Back 8

Contracts with a health insurance plan and accepts whatever the plan pays for procedures and services performed. The PAR is not allowed to bill the patients for the difference (called balance billing).

Front 9

Encounter Form

Back 9

The financial record source document used by healthcare providers to record treated diagnoses and services rendered to the patient during the encounter

Front 10

Clearinghouses

Back 10

Process claims that are filed in a "flat" format and converted to (standard) format.

Front 11

Worker's Compensation

Back 11

Is always considered to be primary to the insurance plan

Front 12

The patient account record

Back 12

Is a permanent record of all financial transaction between the patient and the practice.

Front 13

Copayments

Back 13

Are supposed to be paid at the time of the visit.

Front 14

The birthday rule

Back 14

Is a policy determination for covered children.

Front 15

Day Sheet

Back 15

Chronological summary of all transactions posted on a specific day.

Front 16

Gender Rule

Back 16

States the father's plan is always primary when the child is covered by both parents

Front 17

Primary Insurance

Back 17

The insurance plan responsible for paying health care insurance claims first.

Front 18

SOAP notes

Back 18

Are used in the provider's office to document patient visits.

Front 19

Patient Account Record

Back 19

Is a computerized record of all financial transactions between patients and the practice.

Front 20

Claim Attachment

Back 20

Supporting documentation associated with a healthcare claim for patient encounter

Front 21

Electronic Flat File

Back 21

Clearinghouse claims processing format

Front 22

NonPAR

Back 22

Is a physician who is not contracted with an insurance company.

Front 23

Modifier

Back 23

Reported on claims to provide clarification about procedures and services performed.

Front 24

Value-added Network (VAN)

Back 24

Clearinghouse that involves vendors like banks, in the processing of claims.