NHA CPT Revenue Cycle and Regulatory Compliance

Vocabulary-based flashcards covering the components, terminology, and legal regulations of the medical billing revenue cycle.

Revenue Cycle

The administrative and clinical oversight of day-to-day operations to capture and collect payment for services rendered, beginning with patient registration and ending when final payment is made.

Accounts Receivable

The amount owed to a provider for health care services rendered.

Revenue Cycle Management

The process that health care providers use to manage financial viability by increasing revenue and improving cash flow, from registration to final payment.

Copayment (copay)

A flat, fixed amount that a patient pays for specific services, such as office or emergency department encounters.

Assignment of Benefits

A method of a patient requesting their claim benefits be paid directly to the health care organization that provided the service.

Health Insurance Portability and Accountability Act (HIPAA)

A federal act that governs and mandates regulations that include privacy, confidentiality, and security for health care data and information.

Beneficiary

A person eligible to receive benefits for covered health care services rendered.

Eligibility

The process of verifying the patient has insurance coverage and has benefits for the services to be provided.

Out-of-pocket payment

The patient responsibility portion of a health insurance plan defined by the payer, including the annual deductible, copay, and coinsurance amounts.

Coinsurance

A predetermined percentage the patient is responsible to pay for covered services once the annual deductible has been met.

Deductible

The annual amount the patient must pay before the insurance will begin to pay for covered benefits.

Utilization Management

A method used to control health care cost by reviewing the appropriateness and medical necessity of services rendered prior to the treatment being performed.

Preauthorization

The process of requesting approval for a service or procedure by providing medical history to the insurance to support the medical need for the service.

Precertification

The process of determining a patient’s coverage details for health care services such as laboratory or imaging services, hospitalizations, and surgical procedures.

Medical Necessity

The process of providing diagnosis codes that support the services rendered to the patient, involving the linking of applicable diagnosis codes to service/procedure codes.

Encounter Form

An electronic or paper document that captures diagnoses or procedure codes for the services provided during the patient’s encounter.

Charge Capture

The process of selecting and entering codes ($CPT$, $HCPCS$, $ICD-10-CM$) into the financial portion of the electronic health record (EHR) based on clinical documentation.

Linkage

The process of associating $ICD-10-CM$ codes to $CPT$ and $HCPCS$ codes to support medical necessity within the billing software.

837P Format

The electronic format used by the EHR to generate, process, and submit claims to the payer.

CMS-1500 Form

The paper claim form used to send information to the payer when electronic submission is not utilized.

Electronic Remittance Advice (RA) / Explanation of Benefits (EOB)

Documents transmitted by payers detailing how a claim was processed and paid, used by billers to post adjustments to patient accounts.

Appeals Process

A process used to request reconsideration of a denied claim, involving correcting errors and filing at progressive levels.

Fair Debt Collection Practices Act (FDCPA)

An act that regulates third-party debt collectors’ actions and practices regarding the collection of the patient’s portion of claim reimbursement.

Policyholder

The person in which the insurance is enrolled, also known as the insured.

Dependent

A person included on an insurance policy, such as a spouse or child.

Claim

A request for payment submitted to an insurance company for services rendered.

Benefit

The amount paid by an insurance company for health care services.

Premium

The fee paid to an insurance company to maintain health insurance coverage.