Mod-D

Front 1

Capitated

Back 1

provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year).

Front 2

PPO

Back 2

network of physicians, other health care practitioners, and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee.

Front 3

HMO

Back 3

responsible for providing health care services to subscribers in a given geographical area for a fixed fee

Front 4

Group

Back 4

traditional health care coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals.

Front 5

accept assignment

Back 5

provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts).

Front 6

accounts receivable

Back 6

the amount owed to a business for services or goods provided.

Front 7

accounts receivable aging report

Back 7

shows the status (by date) of outstanding claims from each payer, as well as payments due from patients

Front 8

accounts receivable management

Back 8

assists providers in the collection of appropriate reimbursement for services rendered; includes functions such as insurance verification/ eligibility and preauthorization of services.

Front 9

allowed charge

Back 9

the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy

Front 10

ANSI ASC X12

Back 10

an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims.

Front 11

appeal

Back 11

documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment

Front 12

assignment of benefits

Back 12

the provider receives reimbursement directly from the payer.

Front 13

bad debt

Back 13

accounts receivable that cannot be collected by the provider or a collection agency.

Front 14

beneficiary

Back 14

the person eligible to receive health care benefits

Front 15

birthday rule

Back 15

determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.

Front 16

chargemaster

Back 16

document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill (UB-04).

Front 17

claims adjudication

Back 17

comparing a claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicate; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.

Front 18

claims attachment

Back 18

medical report substantiating a medical condition

Front 19

claims processing

Back 19

sorting claims upon submission to collect and verify information about the patient and provider.

Front 20

claims submission

Back 20

the transmission of claims data (electronically or manually) to payers or clearinghouses for processing

Front 21

clean Claim

Back 21

a correctly completed standardized claim (e.g., CMS-1500 claim).

Front 22

clearinghouse

Back 22

performs centralized claims processing for providers and health plans.

Front 23

closed claim

Back 23

claims for which all processing, including appeals, has been completed.

Front 24

coinsurance

Back 24

also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.

Front 25

common data file

Back 25

abstract of all recent claims filed on each patient.

Front 26

Consumer Credit Protection Act of 1968

Back 26

was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges, compare costs, and shop for the best credit deal.

Front 27

coordination of benefits (COB)

Back 27

provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other policies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.

Front 28

covered entity

Back 28

private sector health plans (excluding certain small self-administered health plans), managed care organizations, ERISA-covered health benefit plans (Employee Retirement Income Security Act of 1974), and government health plans (including Medicare, Medicaid, Military Health System for active duty and civilian personnel; Veterans Health Administration, and Indian Health Service programs); all health care clearinghouses; and all health care providers that choose to submit or receive transactions electronically.

Front 29

day sheet

Back 29

also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.

Front 30

deductible

Back 30

amount for which the patient is financially responsible before an insurance policy provides coverage.

Front 31

delinquent account

Back 31

past due account.

Front 32

delinquent claim

Back 32

claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due

Front 33

delinquent claim cycle

Back 33

advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (e.g., 120 days or more).

Front 34

downcoding

Back 34

assigning lower-level codes than documented in the record

Front 35

electronic data interchange (EDI)

Back 35

computer-to-computer exchange of data between provider and payer.

Front 36

electronic flat file format

Back 36

eries of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers to bill for health care services

Front 37

electronic funds transfer (EFT)

Back 37

system by which payers deposit funds to the provider's account electronically

Front 38

Electronic Funds Transfer Act

Back 38

established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems

Front 39

Electronic Healthcare Network Accreditation Commission (EHNAC)

Back 39

organization that accredits clearinghouses

Front 40

electronic media Claim

Back 40

electronic flat file format

Front 41

electronic remittance advice (ERA)

Back 41

remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly

Front 42

encounter form

Back 42

financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter

Front 43

Equal Credit Opportunity Act

Back 43

prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good faith exercise of any rights under the Consumer Credit Protection Act.

Front 44

Fair Credit and Charge Card Disclosure Act

Back 44

amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-end credit and charge accounts and under other circumstances; this law applies to providers that accept credit cards.

Front 45

Fair Credit Billing Act

Back 45

federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory goods and services; cardholders cannot be held liable for more than $50 of fraudulent charges made to a credit card

Front 46

Fair Credit Reporting Act

Back 46

protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations, including the duty to investigate disputed information

Front 47

Fair Debt Collection Practices Act (FDCPA)

Back 47

specifies what a collection source may and may not do when pursuing payment of past due accounts.

Front 48

guarantor

Back 48

person responsible for paying health care fees.

Front 49

litigation

Back 49

legal action to recover a debt; usually a last resort for a medical practice

Front 50

manual daily accounts receivable journal

Back 50

also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day.

Front 51

noncovered benefit

Back 51

any procedure or service reported on a claim that is not included on the payer's master benefit list, resulting in denial of the claim; also called noncovered procedure or uncovered benefit.

Front 52

nonparticipating provider (nonPAR)

Back 52

does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses

Front 53

open claim

Back 53

submitted to the payer, but processing is not complete.

Front 54

out-of-pocket payment

Back 54

established by health insurance companies for a health insurance plan; usually has limits of $1,000 or $2,000; when the patient has reached the limit of an out-of-pocket payment (e.g., annual deductible) for the year, appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision.

Front 55

outsource

Back 55

contract out

Front 56

participating provider (PAR)

Back 56

contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed.

Front 57

past-due account

Back 57

one that has not been paid within a certain time frame (e.g., 120 days); also called delinquent account

Front 58

patient account record

Back 58

also called patient ledger; a computerized permanent record of all financial transactions between the patient and the practice

Front 59

patient ledger

Back 59

patient account record - documents health care services provided to a patient

Front 60

pre-existing condition

Back 60

any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage

Front 61

primary insurance

Back 61

associated with how an insurance plan is billed—the insurance plan responsible for paying health care insurance claims first is considered primary.

Front 62

Provider Remittance Notice (PRN)

Back 62

remittance advice submitted by Medicare to providers that includes payment information about a claim

Front 63

secondary insurance

Back 63

billed after primary insurance has paid contracted amount

Front 64

SOAP note

Back 64

outline format for documenting health care; “SOAP” is an acronym derived from the first letter of the headings used in the note: Subjective, Objective, Assessment, and Plan.

Front 65

superbill

Back 65

term used for an encounter form in the physician's office

Front 66

source document

Back 66

the routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated.

Front 67

suspense

Back 67

pending

Front 68

Truth in Lending Act

Back 68

was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing money in a common language so that consumers could figure out the charges, compare costs, and shop for the best credit deal.

Front 69

two-party check

Back 69

check made out to both patient and provider

Front 70

unassigned claim

Back 70

generated for providers who do not accept assignment; organized by year.

Front 71

unauthorized service

Back 71

services that are provided to a patient without proper authorization or that are not covered by a current authorization

Front 72

unbundling

Back 72

submitting multiple CPT codes when one code should be submitted.

Front 73

value-added network (VAN)

Back 73

clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers than managing their own systems to send and receive transactions directly from numerous entities.