Summary on Revenue cycle management with
clear Definition
account receivable - The amount owed by a business for services or goods provided
Accept assignment - Provider accepts as payment in full whatever is paid on the claim
by the payer
(except for any copayment and /or coinsurance amounts)
Accounts Receivable Managment - Assists providers in the collection of appropriate
reimbursement for services rendered
Includes functions such as insurance verification/ eligibility and preauthorization of
services
Accounts receivable aging report - shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
ANSI ASC X12N - an electronic format standard that uses a variable-length file format
to process transactions for institutional, professional, dental, and drug claims.
Allowed charges - the maximum amount the payer will reimburse for each procedure
or service, according to the patient's policy
Assignment of benefits - the provider receives reimbursement directly from the payer
Appeal - Documented as a letter
Signed by provider
Explaining why a claim should be recognized for payment
beneficiary - The person eligible to receive health care benefits
Bad debt - accounts receivable that cannot be collected by the provider or a collection
agency.
Birthday rule - determines coverage by primary and secondary policies when each
parent subscribes to a different health insurance plan.
, Charge Description Master (CDM) - See chargemaster
Case management - development of patient care plans to coordinate and provide care
for complicated cases in a cost-effective manner
Chargemaster - document that contains a computer-generated list of procedures,
services, and supplies with charges for each;
chargemaster data are entered in the facility's patient accounting system, and charges
are automatically posted to the patient's bill (UB-04).
chargemaster maintenance - process of updating and revising key elements of the
chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.
chargemaster team - team of representatives from a variety of departments who
jointly share responsibility for updating and revising the chargemaster to ensure
accuracy.
claims adjudication - comparing a claim to payer edits and the patient's health plan
benefits to verify that the required information is available to process the claim;
the claim is not a duplicate;
payer rules and procedures have been followed;
and procedures performed or services provided are covered benefits.
claims adjustment reason code (CARC) - reason for denied claim as reported on the
remittance advice or explanation of benefits.
claims attachment - medical report substantiating a medical condition
claims denial - unpaid claim returned by third-party payers because of beneficiary
identification errors, coding errors, diagnosis that does not support medical necessity of
procedure/service, duplicate claims, global days of surgery E/M coverage issue, NCCI
edits, and other patient coverage issues (e.g., procedure or service required
preauthorization, procedure is not included in patient's health plan contract, such as
cosmetic surgery).
claims processing - sorting claims upon submission 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.
claims rejection - unpaid claim returned by third-party payers because it fails to meet
certain data requirements, such as missing data (e.g., patient name, policy number);
rejected claims can be corrected and resubmitted for processing.
clear Definition
account receivable - The amount owed by a business for services or goods provided
Accept assignment - Provider accepts as payment in full whatever is paid on the claim
by the payer
(except for any copayment and /or coinsurance amounts)
Accounts Receivable Managment - Assists providers in the collection of appropriate
reimbursement for services rendered
Includes functions such as insurance verification/ eligibility and preauthorization of
services
Accounts receivable aging report - shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
ANSI ASC X12N - an electronic format standard that uses a variable-length file format
to process transactions for institutional, professional, dental, and drug claims.
Allowed charges - the maximum amount the payer will reimburse for each procedure
or service, according to the patient's policy
Assignment of benefits - the provider receives reimbursement directly from the payer
Appeal - Documented as a letter
Signed by provider
Explaining why a claim should be recognized for payment
beneficiary - The person eligible to receive health care benefits
Bad debt - accounts receivable that cannot be collected by the provider or a collection
agency.
Birthday rule - determines coverage by primary and secondary policies when each
parent subscribes to a different health insurance plan.
, Charge Description Master (CDM) - See chargemaster
Case management - development of patient care plans to coordinate and provide care
for complicated cases in a cost-effective manner
Chargemaster - document that contains a computer-generated list of procedures,
services, and supplies with charges for each;
chargemaster data are entered in the facility's patient accounting system, and charges
are automatically posted to the patient's bill (UB-04).
chargemaster maintenance - process of updating and revising key elements of the
chargemaster (or charge description master [CDM]) to ensure accurate reimbursement.
chargemaster team - team of representatives from a variety of departments who
jointly share responsibility for updating and revising the chargemaster to ensure
accuracy.
claims adjudication - comparing a claim to payer edits and the patient's health plan
benefits to verify that the required information is available to process the claim;
the claim is not a duplicate;
payer rules and procedures have been followed;
and procedures performed or services provided are covered benefits.
claims adjustment reason code (CARC) - reason for denied claim as reported on the
remittance advice or explanation of benefits.
claims attachment - medical report substantiating a medical condition
claims denial - unpaid claim returned by third-party payers because of beneficiary
identification errors, coding errors, diagnosis that does not support medical necessity of
procedure/service, duplicate claims, global days of surgery E/M coverage issue, NCCI
edits, and other patient coverage issues (e.g., procedure or service required
preauthorization, procedure is not included in patient's health plan contract, such as
cosmetic surgery).
claims processing - sorting claims upon submission 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.
claims rejection - unpaid claim returned by third-party payers because it fails to meet
certain data requirements, such as missing data (e.g., patient name, policy number);
rejected claims can be corrected and resubmitted for processing.
