The Revenue Cycle

Module One Test

1. Registration and Scheduling

Communication between the patient and staff to begin services. Phone, Website, and/or patient portal. Patient provides basic demographic details and insurance.

2. Patient Check-in

Compliance and billing regulations.

Copayments and Deductible

Registration forms- occupation, emergency contact

Assignment of benefits (request of benefit claim), Medical records, release forms, financial policy, HIPPA signed.

Beneficiary and policyholder

verify eligibility

out of pocket

coinsurance

3. Utilization Management Review

Determines when referrals, Preauthorization’s- services/procedures, Precertification-screening for medical necessity.

4. Healthcare Encounter and Documentations

Patient encounter performed and supporting documents notes. AI, recordings, transcripts, and scribes

5. Charge Capture and Coding

Process of selecting and entering codes.

*CPT- procedure and labs

*HCPCS- Drugs and supplies

*ICD-10-CM- signs and symptoms

based on documents in patients record and entered into financial portion or practice management systems.

*EHR- electronic health record

Codes predetermined from encounter form or withing EHR database

6. Patient Check-Out

Detemins out-of-pocket expenses. Follow ups, Instructions, Referrals to other providers and any consent forms

7. Billing

Charges are validated and transmitted

EHR generates, processes, and submitted

• 837p format-electronically

• CMS-1500 form- Printed/Paper

*Payer- Insurance

8. Payer Adjudication

Payer reviews the claim and reimburse services at the allowed (or contracted-agree to pay) amount or apply the charges to deductible or copay/coinsurance amounts.

9. Receiving and Posting Reimbursement

RA- electronic remittancce advice (providers office)

EOB- Explanation of benefits (patients)

10. Appeals and Claims Corrections

Claims that are denied can be corrected or appealed.

• rejected claims can not be appealed

Patient Responsibility Collection, Payment, and Posting

Any patient responsibility amounts. specified on the RA/EOB must be collected.

Remaining amounts such as deductible or coinsurances. (Ex. Hospital, Collections etc.)