Revenue Cycle Management Chapter. 4
Reviews and Questions 2023/2024
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 - the amount owed to a business for services or goods
provided.
accounts receivable aging report - shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
accounts receivable management - assists providers in the collection of appropriate
reimbursement for services rendered; includes functions such as insurance
verification/eligibility and pre-authorization of services.
allowed charges - the maximum amount the payer will reimburse for each procedure
or service, according to the patient's policy.
ANSI ASC X12N - an electronic format standard that uses a variable-length file
format to process transactions for institutional, professional, dental, and drug claims.
appeal - documented as a letter, signed by the provider, explaining why a claim
should be reconsidered for payment.
assignment of benefits - the provider receives reimbursement directly from the payer.
bad debt - accounts receivable that cannot be collected by the provider or a
collection agency.
beneficiary - the person eligible to receive health care benefits.
birthday rule - determines coverage by primary and secondary policies when each
parent subscribes to a different health insurance plan.
case management - development of patient care plans to coordinate and provide
care for complicated cases in a cost-effective manner.
,charge description master (CDM) - 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 - 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 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.
claims submission - the transmission of claims data (electronically or manually) to
payers or clearinghouses for processing.
clean claim - a correctly completed standardized claim (e.g., CMS-1500 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 generate reimbursement to the provider.
closed claim - claims for which all processing, including appeals, has been
completed.
coinsurance - also called coinsurance payment; the percentage the patient pays for
covered services after the deductible has been met and the copayment has been paid.
common data file - abstract of all recent claims filed on each patient.
concurrent review - review for medical necessity of tests and procedures ordered
during an inpatient hospitalization.
Consumer Credit Protection Act of 1968 - was considered landmark legislation
because it launched truth-in-lending disclosures that required creditors to communicate
the cost of borrowing money in a common language so that consumers could figure out
the charges, compare costs, and shop for the best credit deal.
coordination of benefits (COB) - provision in group health insurance policies that
prevents multiple insurers from paying benefits covered by other policies; also specifies
that coverage will be provided in a specific sequence when more than one policy covers
the claim.
covered entity - private sector health plans (excluding certain small self-administered
health plans), managed care organizations, ERISA-covered health benefit plans
(Employee Retirement Income Security Act of 1974), and government health plans
(including Medicare, Medicaid, Military Health System for active duty and civilian
personnel; Veterans Health Administration, and Indian Health Service programs); all
health care clearinghouses; and all health care providers that choose to submit or
receive transactions electronically.
data analytics - tools and systems that are used to analyze clinical and financial
data, conduct research, and evaluate the effectiveness of disease treatments.
data mining - extracting and analyzing data to identify patterns, whether predictable
or unpredictable.
data warehouse - database that use reporting interfaces to consolidate multiple
databases, allowing reports to be generated from a single request; data is accumulated
from a wide range of sources within an organization and is used to guide management
decisions.
Reviews and Questions 2023/2024
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 - the amount owed to a business for services or goods
provided.
accounts receivable aging report - shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
accounts receivable management - assists providers in the collection of appropriate
reimbursement for services rendered; includes functions such as insurance
verification/eligibility and pre-authorization of services.
allowed charges - the maximum amount the payer will reimburse for each procedure
or service, according to the patient's policy.
ANSI ASC X12N - an electronic format standard that uses a variable-length file
format to process transactions for institutional, professional, dental, and drug claims.
appeal - documented as a letter, signed by the provider, explaining why a claim
should be reconsidered for payment.
assignment of benefits - the provider receives reimbursement directly from the payer.
bad debt - accounts receivable that cannot be collected by the provider or a
collection agency.
beneficiary - the person eligible to receive health care benefits.
birthday rule - determines coverage by primary and secondary policies when each
parent subscribes to a different health insurance plan.
case management - development of patient care plans to coordinate and provide
care for complicated cases in a cost-effective manner.
,charge description master (CDM) - 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 - 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 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.
claims submission - the transmission of claims data (electronically or manually) to
payers or clearinghouses for processing.
clean claim - a correctly completed standardized claim (e.g., CMS-1500 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 generate reimbursement to the provider.
closed claim - claims for which all processing, including appeals, has been
completed.
coinsurance - also called coinsurance payment; the percentage the patient pays for
covered services after the deductible has been met and the copayment has been paid.
common data file - abstract of all recent claims filed on each patient.
concurrent review - review for medical necessity of tests and procedures ordered
during an inpatient hospitalization.
Consumer Credit Protection Act of 1968 - was considered landmark legislation
because it launched truth-in-lending disclosures that required creditors to communicate
the cost of borrowing money in a common language so that consumers could figure out
the charges, compare costs, and shop for the best credit deal.
coordination of benefits (COB) - provision in group health insurance policies that
prevents multiple insurers from paying benefits covered by other policies; also specifies
that coverage will be provided in a specific sequence when more than one policy covers
the claim.
covered entity - private sector health plans (excluding certain small self-administered
health plans), managed care organizations, ERISA-covered health benefit plans
(Employee Retirement Income Security Act of 1974), and government health plans
(including Medicare, Medicaid, Military Health System for active duty and civilian
personnel; Veterans Health Administration, and Indian Health Service programs); all
health care clearinghouses; and all health care providers that choose to submit or
receive transactions electronically.
data analytics - tools and systems that are used to analyze clinical and financial
data, conduct research, and evaluate the effectiveness of disease treatments.
data mining - extracting and analyzing data to identify patterns, whether predictable
or unpredictable.
data warehouse - database that use reporting interfaces to consolidate multiple
databases, allowing reports to be generated from a single request; data is accumulated
from a wide range of sources within an organization and is used to guide management
decisions.
