NHA CBCS Chapter 4 - Payment
Adjudication
Account Number - ANS-Number that identifies specific episodes of care, DOS , or patient.
\Accounts Receivable Department - ANS-Department that keeps track of what 3rd party
payers the provider is waiting to hear from and what patients are due to make a payment.
\Advance Beneficiary Notice of Noncoverage - ANS-Form used when a provider believes
Medicare will deny coverage because they deem the procedure unnecessary.
\After requesting an appeal the insurance company must: - ANS-- Respond within 72 hours
for urgent care.
- Within 30 days for denials of care not yet received.
- Within 60 days for services already received.
\Age Trial Balance (ATB) - ANS-Status of an invoice pending payment from insurance and/or
patient. (Managed in 30 day increments)
\Aging Report - ANS-Measures the outstanding balances in each account and helps staff
see what accounts haven't been paid.
\Appeals - ANS-Insurance Company must provide:
- Reasons claim was denied
- The right of the patient to file an internal appeal
- Patients right to external review
- ID whether a Consumer Assistance Program is available
\balance billing - ANS-Billing patients for charges in excess of the Medicare fee schedule.
\batch - ANS-A group of submitted claims.
\Billed Amount (Actual Charge) - ANS-The amount the provider charges for services; may
not be the same as the allowable charge.
\Charge Description Manager (CDM) - ANS-Information about health care services that
patients have received and financial transactions that have taken place.
\Cost Sharing - ANS-The balance the policyholder must pay to the provider.
\Denial Codes - ANS-Group, CARCs, RARCs, Provider-Level
\Explanation of Benefits (EOB) - ANS-Describes the services rendered, payment covered,
and benefits limits and denials.
\Health Record Number - ANS-Number the provider uses to ID an individual patient's record.
\Medicare Summary Notice ( MSN) - ANS-Document that outirs the amounts billed by the
provider and what the patient must pay the provider.
\Notice of Exclusions from Medicare Benefits - ANS-Notification that a service will not be
paid.
\Reasons for Lack of Payment - ANS-- 3rd party hasn't processed the claim.
- Patient hasn't paid balance.
- Held up in office waiting for provider to give information.
\Reconciliation and Collections (Posting Payment) - ANS-Final step of the revenue cycle
where the provider receives reimbursement from the insurance company and what the
patient owes the provider. (Accounts can also be reconciled through adjustments or
write-offs)
Adjudication
Account Number - ANS-Number that identifies specific episodes of care, DOS , or patient.
\Accounts Receivable Department - ANS-Department that keeps track of what 3rd party
payers the provider is waiting to hear from and what patients are due to make a payment.
\Advance Beneficiary Notice of Noncoverage - ANS-Form used when a provider believes
Medicare will deny coverage because they deem the procedure unnecessary.
\After requesting an appeal the insurance company must: - ANS-- Respond within 72 hours
for urgent care.
- Within 30 days for denials of care not yet received.
- Within 60 days for services already received.
\Age Trial Balance (ATB) - ANS-Status of an invoice pending payment from insurance and/or
patient. (Managed in 30 day increments)
\Aging Report - ANS-Measures the outstanding balances in each account and helps staff
see what accounts haven't been paid.
\Appeals - ANS-Insurance Company must provide:
- Reasons claim was denied
- The right of the patient to file an internal appeal
- Patients right to external review
- ID whether a Consumer Assistance Program is available
\balance billing - ANS-Billing patients for charges in excess of the Medicare fee schedule.
\batch - ANS-A group of submitted claims.
\Billed Amount (Actual Charge) - ANS-The amount the provider charges for services; may
not be the same as the allowable charge.
\Charge Description Manager (CDM) - ANS-Information about health care services that
patients have received and financial transactions that have taken place.
\Cost Sharing - ANS-The balance the policyholder must pay to the provider.
\Denial Codes - ANS-Group, CARCs, RARCs, Provider-Level
\Explanation of Benefits (EOB) - ANS-Describes the services rendered, payment covered,
and benefits limits and denials.
\Health Record Number - ANS-Number the provider uses to ID an individual patient's record.
\Medicare Summary Notice ( MSN) - ANS-Document that outirs the amounts billed by the
provider and what the patient must pay the provider.
\Notice of Exclusions from Medicare Benefits - ANS-Notification that a service will not be
paid.
\Reasons for Lack of Payment - ANS-- 3rd party hasn't processed the claim.
- Patient hasn't paid balance.
- Held up in office waiting for provider to give information.
\Reconciliation and Collections (Posting Payment) - ANS-Final step of the revenue cycle
where the provider receives reimbursement from the insurance company and what the
patient owes the provider. (Accounts can also be reconciled through adjustments or
write-offs)
