NHA CBCS Study Guide!
Adjudication
The process where the insurance company receives a claim and makes a determination on
payment or denial.
Allowed Amount
The maximum amount an insurance company will pay for the service, procedure, or supply.
Auditing Process
The act of reviewing and comparing the patient medical records and claims to assess for coding
appropriateness and completeness of the medical documentation.
Coding Compliance
The conformity and adherence to established coding guidelines and regulations.
Current Procedural Terminology (CPT)
Descriptive definitions used to explain procedures and services provided to the patient.
Denied Claim
A claim returned from a third-party payer because of technical errors or patient coverage errors.
Explanation of Benefits (EOB)
Document that explains how the payer processed the claim for services rendered; can also be
referred to as remittance advice (RA).
Fee-for-Service
Cost or fee that is charged for each individual service.
Health and Human Services
,Government department that oversees the health of the community and provides crucial
services.
International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM)
List of codes used to report and classify diseases, conditions and other reasons for health care
encounters.
Noncompliance
The act of disregarding rules and guidelines outlined by state and federal government agencies
and third-party payers.
Office of Inspector General (OIG)
Government department that investigates fraud and abuse.
Place of Service (POS) Code
Two-digit code that identifies where the services were performed.
Abuse
Billing patterns and practices that are excessive or unnecessary but not fraudulent. - When the
provider unknowingly or unintentionally misrepresented information on a claim for
reimbursement.
Accounts Receivable
The amount owed to a provider for health care services rendered.
Appeals Process
A process used to request review of a claim that was denied---to determine if the denial was
due to a billing error; if so, correct it; file an appeal at the lowest level; and then move up to
higher levels if needed.
Assignment of Benefits
Method of a patient requesting their claim benefits be paid to the health care organization that
provided the service.
Beneficiary
,Person eligible to receive benefits for covered health care services rendered.
Coinsurance
Predetermined percentage the patient is responsible to pay for covered services once the
annual deductible has been met.
Copayment (copay)
Flat, fixed amount that a patient pays for specific services (e.g., office or Emergency
Department encounters). // Many policies have a $25 copay for PCP office visits and $35-$50
copay for specialists)
Covered Entity
Entity that transmits health information in electronic form (e.g., providers, health plans,
clearinghouses)
Deductible
The annual amount the patient must pay before the insurance will begin to pay for covered
benefits.
Electronic Data Interchange (EDI)
Computer technology that contains the exchange of data between the health care provider and
payer.
Eligibility
Process of verifying the patient has insurance coverage and has benefits for the services to be
provided.
Encounter form
Document that captures diagnoses or procedure codes for the services provided during the
patient's encounter (electronic or paper format).
Fraud
Intentionally billing for services not performed, reporting fraudulent diagnoses, or medical coding
errors. - Intentionally expecting a payment on a claim when the provider is aware of wrongdoing,
billing for services that were not provided.
, Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Federal act that governs and mandates regulations that include privacy, confidentiality, and
security for health care data and information.
Medical Necessity
Process of providing diagnosis codes that support the services rendered to the patient; coding
for medical necessity involves associating applicable diagnosis codes (ICD-10-CM) to
service/procedure codes (CPT) within the billing software, which is referred to as linking/linkage.
Out-of-Pocket
Patient responsibility portion of a health insurance plan defined by the payer (includes annual
deductible, copay, and coinsurance amounts).
Preauthorization
The approval for a service or procedure, and timely filing is the time frame to submit a claim.
Precertification
Process of determining a patient's coverage details for health care services (e.g., laboratory or
imaging services, hospitalizations, surgical procedures).
Protected Health Information (PHI)
Individually identifiable patient information.
Revenue Cycle Management (RCM)
Process that health care providers use to manage financial viability by increasing revenue,
improving cash flow, from registration to final payment.
Third-Party Payer
Health care insurance company that reimburses services provided by providers and/or health
care organizations.
Utilization Management
Method used to control health care cost, by reviewing the appropriateness and medical
necessity of services rendered to the patients prior to the treatment being performed.
Adjudication
The process where the insurance company receives a claim and makes a determination on
payment or denial.
Allowed Amount
The maximum amount an insurance company will pay for the service, procedure, or supply.
Auditing Process
The act of reviewing and comparing the patient medical records and claims to assess for coding
appropriateness and completeness of the medical documentation.
Coding Compliance
The conformity and adherence to established coding guidelines and regulations.
Current Procedural Terminology (CPT)
Descriptive definitions used to explain procedures and services provided to the patient.
Denied Claim
A claim returned from a third-party payer because of technical errors or patient coverage errors.
Explanation of Benefits (EOB)
Document that explains how the payer processed the claim for services rendered; can also be
referred to as remittance advice (RA).
Fee-for-Service
Cost or fee that is charged for each individual service.
Health and Human Services
,Government department that oversees the health of the community and provides crucial
services.
International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM)
List of codes used to report and classify diseases, conditions and other reasons for health care
encounters.
Noncompliance
The act of disregarding rules and guidelines outlined by state and federal government agencies
and third-party payers.
Office of Inspector General (OIG)
Government department that investigates fraud and abuse.
Place of Service (POS) Code
Two-digit code that identifies where the services were performed.
Abuse
Billing patterns and practices that are excessive or unnecessary but not fraudulent. - When the
provider unknowingly or unintentionally misrepresented information on a claim for
reimbursement.
Accounts Receivable
The amount owed to a provider for health care services rendered.
Appeals Process
A process used to request review of a claim that was denied---to determine if the denial was
due to a billing error; if so, correct it; file an appeal at the lowest level; and then move up to
higher levels if needed.
Assignment of Benefits
Method of a patient requesting their claim benefits be paid to the health care organization that
provided the service.
Beneficiary
,Person eligible to receive benefits for covered health care services rendered.
Coinsurance
Predetermined percentage the patient is responsible to pay for covered services once the
annual deductible has been met.
Copayment (copay)
Flat, fixed amount that a patient pays for specific services (e.g., office or Emergency
Department encounters). // Many policies have a $25 copay for PCP office visits and $35-$50
copay for specialists)
Covered Entity
Entity that transmits health information in electronic form (e.g., providers, health plans,
clearinghouses)
Deductible
The annual amount the patient must pay before the insurance will begin to pay for covered
benefits.
Electronic Data Interchange (EDI)
Computer technology that contains the exchange of data between the health care provider and
payer.
Eligibility
Process of verifying the patient has insurance coverage and has benefits for the services to be
provided.
Encounter form
Document that captures diagnoses or procedure codes for the services provided during the
patient's encounter (electronic or paper format).
Fraud
Intentionally billing for services not performed, reporting fraudulent diagnoses, or medical coding
errors. - Intentionally expecting a payment on a claim when the provider is aware of wrongdoing,
billing for services that were not provided.
, Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Federal act that governs and mandates regulations that include privacy, confidentiality, and
security for health care data and information.
Medical Necessity
Process of providing diagnosis codes that support the services rendered to the patient; coding
for medical necessity involves associating applicable diagnosis codes (ICD-10-CM) to
service/procedure codes (CPT) within the billing software, which is referred to as linking/linkage.
Out-of-Pocket
Patient responsibility portion of a health insurance plan defined by the payer (includes annual
deductible, copay, and coinsurance amounts).
Preauthorization
The approval for a service or procedure, and timely filing is the time frame to submit a claim.
Precertification
Process of determining a patient's coverage details for health care services (e.g., laboratory or
imaging services, hospitalizations, surgical procedures).
Protected Health Information (PHI)
Individually identifiable patient information.
Revenue Cycle Management (RCM)
Process that health care providers use to manage financial viability by increasing revenue,
improving cash flow, from registration to final payment.
Third-Party Payer
Health care insurance company that reimburses services provided by providers and/or health
care organizations.
Utilization Management
Method used to control health care cost, by reviewing the appropriateness and medical
necessity of services rendered to the patients prior to the treatment being performed.
