EMR (Cengage MINDTAP) Glossary Terms Flashcards

Encounter forms

also known as superbill, a charge ticket, or visit/fee slip; contains all of the information insurance companies require in order to consider a claim for payment

superbills

also known as an encounter form, a charge ticket, or visit/fee slip; contains all of the information insurance companies require in order to consider a claim for payment

CPT

a medical code set maintained by the American Medical Association (AMA). Each CPT code identifies a medical, surgical, or diagnostic procedure or service performed.

Medical Billing

Day sheet

provides a summary of financial transactions; for example, charges, payments, and adjustments (also known as a journal)

Deposit date

the date funds are expected to be deposited at a financial institution, such as a bank

Crossover claim

the transfer or forwarding of completed claim information from Medicare to Medicaid, Medi-Cal, or private insurance companies that provide supplemental insurance benefits to Medicare beneficiaries

Dunning message

a communication included on statements that alert the recipient of information regarding the amount due. Dunning messages assist in clarifying the balance due to encourage prompt payments.

EIN/FEIN

an acronym for Federal Employer Identification Number, also known as EIN (Employer Identification Number). A FEIN is a nine-digit unique number assigned by the Internal Revenue Service (IRS) to identify a business operating in the United States.

Explanation code

the explanation codes column contains Remittance Advice Remark Codes (RARCs), which provide the explanation for an adjustment or payment, or a lack of payment due to a specific reason

Matched claim

an ERA transaction that matches the charges on a patient account and is ready for posting

Global

a term used to mean "all" or "applicable to everything". In terms of a global dunning message, the message appears on all statements generated to be sent to patients.

MSP code

codes that are used to explain why Medicare is the secondary payor for a patient's claim

Non-Matched claim

an ERA transaction that does not match due to an issue that needs further follow-up, edits, or completion in order for the payer to reimburse for the service. Unmatched services need to be followed up and resolved before posting of payments and adjustments can be applied.

NOS

number of service, or the number of units of service provided to the patient

Posting date

the date funds are allocated to the balance due of an account

point-of-service plan (POS)

insurance coverage that offers an in-network and an out-of-network option to receive services. When using the plan in-network, it is usually an HMO model with a PCP and referrals needed for specialists. When used out-of-network, there is a higher out of pocket cost to the patient; however, a PCP and referrals are not required.

Reverse a payment

a process by which the original charges, and applicable fees, are charged back to an account after a payment was not honored or paid due to non-sufficient funds (NSF) or other reason. The amount reversed will show as due in the balance.

Post payment

to allocate funds to the balance due of an account

Takeback

a sum of money an insurance carrier requests be refunded because there was a duplicate payment, the patient's coverage was terminated, or the claim was overpaid

Service Date

the date medical services or procedures were provided to the patient (DOS - Date of Service)

Statement service

a third party service that receives data from the clinic on which patients will be sent a statement with balances due, and prepares the actual statement, envelopes for mailing, and may include a method for paying online. The service may include online reports, confirming clean addresses, and discounted postage rates. If a service is not used, the clinic will need to print the statements, stuff envelopes, and supply address and postage for mailing.

Transaction Class and Transaction Type

refers to the available financial transactions in the EMR such as patient payments (Cash or Check); Insurance Check, Patient Refund, and more

X12

ASC X12 (also known as ANSI ASC X12) is the official designation of the U.S. national standards body for the development and maintenance of Electronic Data Interchange (EDI) standards. When submitting insurance claims, the clearinghouse uses the X12 standard for transmission.

payer

an entity other than the patient that reimburses expenses for health care services. These include insurance companies, or other third party payers, such as No-fault insurance, Workers Comp, or other responsibility party.

Payee

a name to reference the insured on the policy, or the party entitled to payment, such as the provider or facility

NSF

non-sufficient funds is an acronym used to describe a check that is returned non-paid by a bank due to the account not having funds to cover the payment. Also known as a returned check.

adjustments

a sum of money that is written off a patient's account for any reason. An example would be the amount between the charges and allowed amount that is not collected due to contractual agreement.

batch

assigns a name and establishes defaults to a group of financial transactions

charges

fees for procedures performed or services rendered

aging

the classification of accounts by the time elapsed after the date of billing or the due date

journal

provides a summary of financial transactions; for example, charges, payments, and adjustments (also known as a day sheet)

aging report

a report that shows insurance claims that are unpaid or patient accounts that are in arrears. The usual aging time frames are current (0-30 days) and past due (31-60, 61-90, 91-120, and >120 days). Claims or patient accounts that are past due should be checked on starting at 30 days.

accounts receivable

arise when a company provides goods or services on credit; money that is owed to your group broken out by financial class (e.g., Private Pay, Medicare, Blue Shield, Commercial, etc.) and also by age (e.g., current to 30 days old, 31 to 60 days old, etc.)

Remittance Advice (RA)

also known as an EOB (Explanation of Benefits). A document that provides details on claims billed to the insurance, and how the claims were paid, including information on allowable, deductibles, adjustments, and the net payment. The RA or EOB may be accompanied by a payment in the form of a check, or refers to an electronic funds transfer (EFT).

Electronic Remittance Advice (ERA)

an electronic report provided in a computer-readable format sent by insurance companies to health care service providers, which explains the payment of medical claims; an electronic version of an Explanation of Benefits (EOB)

Date of service

the date a medical service or procedure is actually provided or rendered

electronic funds transfer (EFT)

also known as direct deposit; transfers payments from the insurance company directly into the provider's bank account. By enrolling in ERA and EFT, insurance payments are received more quickly and it is simpler to post and reconcile patient accounts.

medical claim

a bill submitted to an insurance carrier for reimbursement of medical services or procedures rendered to a patient by a provider

Patient Collections

Responsible party

the individual who is responsible for any private pay balances; the remaining amount, if any, after insurance has paid its portion

patient collections

the act of collecting patient balances