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