Chapter 30: Billing and Reimbursement
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11 Terms
What is a claim?
Request for payment submitted to insurance.
What is the CMS-1500 form used for?
Professional/physician outpatient claims.
What is an EOB?
Explanation of Benefits showing what insurance paid/denied and patient responsibility.
What is an ERA?
Electronic Remittance Advice.
What is a clean claim?
Claim with accurate, complete information that can be processed without delay.
What causes claim denial?
Incorrect patient/insurance data, invalid codes, lack of authorization, noncovered service, or missing documentation.
What is assignment of benefits?
Patient authorizes insurance payment directly to the provider.
What is accounts receivable?
Money owed to the practice.
What is the correct order for payment posting?
Post insurance payment → post adjustments → identify patient balance → send statement per policy.
What is timely filing?
Insurer deadline for submitting claims.
What should the MA verify before submitting a claim?
Patient demographics, insurance, codes, provider information, date of service, and authorization/referral if required.