Revenue Management Vocab

accounts receivable aging report

shows the status (by date) of outstanding claims from each payer, as well as payments due from patients

allowed charges

the maximum amount the payer will reimburse for each procedure or service, accoring to the patient’s policy

ANSI ASC X12 835 TR3

standard format for electonic remittance advice (ERA) transactions that contains information about payment, denials, and pending status claims; abbreviated as 835

ANSI ASC X12N 837

an electronic format standard that uses a variable-length file format to process transactions for institutional, professional, dental, and drug claims; abbreviated as 837

ANSI ASC X12N 837I

standard format for submission of electronic claims for institutional health care services; abbreviated as 837I

ANSI ASC X12N 837P

standard format for submission of electronic claims for professional health care services; abbreviated as 837P

appeal

documented as a letter and signed by the provider, to explain why a claim should be reconsidered for payment

bad dept

accounts receivable that cannot be collected by the provider or a collection agency

beneficiary

the person eligible to receive health care benefits

claims adjudication

completed prior to determining reimbursement by comparing a claim to payer edits and the patien’s health plan benefits to verify that required information is available to process the claim, the claim is not a duplicate, payer rules and procedures were followed, and procedures performed and services provided are covered benefits

claims adjustment reason codes (CARC)

reason for denied claim as reported on the remittance advice or explanation of benefits

claims attachment

medical report substantiating a medical condition

claims management

completion, submission, and follow-up of claims for procedures and services provided

claims processing

sorting claims upon submissio to collect and verify information about the patient and provider

claims submission

the transmission of claims data (electronically or manually) to payers or clearinghouses for processing

clean claim

a correctly completed standardized claim

clearinghouse

agency or organization that collects, processes, and distributes health care claims after editing and validating them to ensure that they are error-free, reformatting them to the payer’s specifications, and submitting them electronically to the appropriate payer for further processing to tgenerate reimbursement to the provider

closed claims

claims for which all processing, including appeals, has been completed

common data file

summary abstract report of all recent claims on each patient

covered entity

private-sector health plans, managed care organizations, ERISA-covered health benefit plans, and government health plans; all health care clearinghouses; and all health care providers that choose to submit or receive transactions electronically

delinguent claims

claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due

delinquent claim cycle

advances through various agin periods, with practices typically focusing internal recovery efforts on older delinquent accounts

denied claims

claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues

downcoding

assigning lover-level codes than documented in the record

electronic data interchange (EDI)

computer-to-computer exchange of data between provider and payer

electronic flat file format

series of fixed-length records submitted to pays to bill for health care services

electronic funds transfer (EFT)

system by which payers electronically deposit funds to the provider’s bank account

electronic remittance advice (ERA)

the X12 835 TR3 (or an 835) electronic document that contains information about payment, denials, and pending status of claims

explanation of benefits (EOB)

document sent to the patient by the third-party payer to provide details about the results of claims processing, such as provider charge, payer fee shcedule, payment made by the payer, and patient finacnial responisiblity; Medicare EOB is called a Medicare summary Notice or MSN

fragmentation

also known as unbundling, submitting mulitple CPT codes when one code should be submitted

litigation

legal action to recover a dept; usually a last resort for a medical practice

Medicare Remittance Advice

an electronic remittance advice (ERA) or standard paper remit (SPR) sent to providers by Medicare administrative contractors, which contain details about claims adjudication and contains information about payments, deductibles and copayments, adjustments, denials, missing or incorrect data, refunds, and claims withheld due to Meciare Secodnary Payer (MSP) or penalty situations

noncovered benefit

any procedure or service reported on a claim that is not included on the payer’s master benefit list, resulting in denial of the claim; also called nonvocered procedure or uncovered benefit

open claims

submitted to the payer, but processing is not complete

outsource

contract out

past-due account

one that has not been paid within a certain time frame; also called delinquent account

peer review

appeal process that involves review by a medical reviewer or a medical director, and if an appeal is escalated, an independent external reviewer may assess the appeal

place of service (POS)

the physical location where health care is provded to patients

place of service (POS) code

two-digit codes that describe settings where professional services are provided; are reported on professional claims

pre-existing condition

any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the policyholder’s effective date of coverage

remittance advice

electronic remittance advice (ERA) or standard paper remit (SPR) sent to providers by third-party payers that contains details about claims adjudication, including information about payments, deductibles and copayments, adjustments, budnling, denials, missing or incorrect data, refunds, claims splitting due to coinsurance and secondary or supplemental payers, and claims withheld due to third-party liability or penalty situations

remittance advice remark codes (RARC)

additional explanation of reasons for denied claims

skip tracing

practice of locating patients to obtain payment of a bad dept; uses credit reports, databases, criminal background checks, and other methods

source document

the routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated

suspense

pending

unassigned claims

generated for providers who do not accept assignment; organized by year

unauthorized services

services that are provided to a patient without proper preauthorization or that are not covered by a current preauthorization

unbundling

submitting multiple CPT codes when one code should be submitted

upcoding

assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement