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32 Cards in this Set
- Front
- Back
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Rider |
Document that modifies on insurance contract |
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Adjudication |
Payer's processing of claim, to determine benefits |
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Determination |
Payer's decision regarding whether to pay a claim |
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Utilization review |
Payers initial claim review & may reject |
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Manual review |
Payer's claim removed from the automated processing system |
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Retention schedule |
Time in length records are kept |
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Waiting period |
Time between the insured's date of enrollment & date of insurance coverage is effective |
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Pre certification |
Pre-authorization for hospital admission or outpatient procedure |
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Elective surgery |
Nonemergency surgical procedure schedule in advanced |
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Host plan |
Participating providers local BCBS plan |
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PPO |
Preferred provider organization ( for-profit) |
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HMO |
Health maintenance organization |
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Subscriber |
The insured |
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Basic coverage covers |
Hospitalization, surgery, laboratory text, x-Ray |
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Major medical coverage covers |
Office visits |
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What does stop loss provision do? |
Prevents risk of large losses or claim experience |
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If a provider does not accept assignment , the payer sends the payment to ? |
The patient |
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Where are eligible members of a capitated plans listed? |
Monthly enrollment list |
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What is ERISA ? |
Self-funded health plan (Walmart ) |
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What is carve out plan? |
Remove part of plan; omit |
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What is home plan? |
BCBS plan in the community the subscriber did the contract for coverage |
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What is an insurance aging report cover? |
Unpaid claims; used in collections |
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What are the advantages of an EFT? |
Faster, cheaper & can get direct deposit . |
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The payer's decision regarding whether to pay a claim is called? |
Determination |
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What is the time frame during which Medicare claims can be appealed? |
6 months |
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Describe what a current invoice. |
Consists of: 0-30 days (current), 31-60days (past due), 61-90 days (final notice) |
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Reasons why a payer may downcode a claim |
If report procedure doesn't match the procedure or documentation doesn't support the level of service |
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What are adjustments |
Correcting patient's account balance |
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If claim was removed from a payer's automated processing system , it's sent for? |
Manual review |
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When a claim is pulled by a payer for manual review, they may ask the provider to submit additional information like what? |
Clinical documentation |
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In most physical physician practices, how soon they follow up on transmitted claims? |
14 days |
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Tracer |
Written inquiry about status of submitted claims |
