Medical Billing Processes Flashcards

This set of vocabulary flashcards covers essential terms, definitions, and concepts related to the medical billing and revenue cycle workflow based on the training transcript.

Medical billing

The administrative and financial process that converts a patient's visit, procedure, or service into a claim that can be submitted to a payer and then followed until the balance is fully resolved.

Revenue cycle

The complete financial journey of a patient encounter, beginning before the visit and ending when every valid dollar has been collected or properly adjusted.

Clean claim

A claim that is complete, accurate, and ready for adjudication without avoidable intervention.

Adjudication

The payer's review process in which the claim is analyzed against policy coverage, provider contract terms, coding rules, medical necessity requirements, coordination of benefits, and prior authorization records.

Allowed amount

The maximum amount a payer recognizes for a covered service under the patient's policy or the provider's contract.

Charge entry

The process of entering billable codes, units, provider data, and related claim information into the billing system.

Clearinghouse

An intermediary that receives claim files, checks them, and forwards them to payers.

Coinsurance

The patient's share of a covered service after deductible requirements are met, usually expressed as a percentage.

Contractual adjustment

The required reduction between the provider's charge and the payer's allowed amount under contract.

Coordination of benefits

The process of determining the order in which multiple insurance plans pay to ensure the remaining balance is considered after primary adjudication.

Copay

A fixed amount the patient owes for a covered service under plan rules.

Deductible

The amount the patient must pay before certain insurance benefits begin to pay.

Denial

An adjudicated claim or service line that the payer did not pay as submitted.

Diagnosis pointer

The linkage on a claim showing which specific $ICD-10-CM$ diagnosis code supports a particular procedure line ($CPT$ or $HCPCS$) to explain medical necessity.

EOB or ERA

The payer's explanation of how a claim was processed, providing details on allowed amounts, paid amounts, adjustments, and patient responsibility.

Medical necessity

The standard used by payers to determine whether a service is reasonable and covered for the documented condition.

Patient responsibility

The portion of the allowed claim balance properly assigned to the patient under policy rules, including deductible, coinsurance, and copayments.

Rejection

A claim that could not enter the normal adjudication process because of a formatting or data issue, often identified at the clearinghouse level.

Remittance

The payer's payment information and adjustment detail shared with the provider.

Resubmission

Sending a corrected or replacement claim after fixing an identified issue with a previous submission.

Timely filing

The deadline within which a claim, corrected claim, or appeal must be received according to payer rules.

Underpayment

A situation in which the payer paid less than expected under policy or contract, requiring review and possible follow-up.

Accounts receivable (A/R)

Money owed to the practice for services already rendered, requiring active follow-up to ensure claims do not age without action.

Work queues

A structured system used to organize claims needing attention, prioritized by factors such as age, dollar value, filing risk, or payer.

Claim scrubbing

The process of checking a claim against internal edits to identify technical, coding, and payer-specific errors before transmission.

$$CMS-1500$$

The common claim format used for professional outpatient medical billing, equivalent to the electronic $837P$ format.

Variance review

The analytical process of comparing the expected payment amount to the actual payment received to identify contract loading problems or adjudication errors.

Credit balance

A situation occurring when over-collection exists due to duplicate payments, patient payments before insurance processing, or incorrect adjustment postings.