Module 1 The Revenue Cycle and Regulatory Compliance Vocab

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; is so, correct it: file an appeal at the lowest level; and then move up to higher levels if needed

Deductible

Annual amount the patient must pay before the insurance will begin to pay for covered benefits

Abuse

Billing patterns and practices that are excessive or unnecessary but not fraudulent.

Electronic Data Interchange (EDI)

Computer technology that contains the exchange of data between the health care provider and payer.

Protected Health Information (PHI)

Individually identifiable patient information.

Fraud

Intentionally billing for services not performed, reporting fraudulent diagnosis, or medical coding errors.

Assignment of Benefits

Method of a patient requesting their claim benefits be paid to the health care organization that provided the service.

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.

Out-of-Pocket Payment

Patient responsibility portion of a health insurance plan defined by the payer (Includes annual deductible, copay, and coinsurance amounts.)

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.

Precertification

Process of determining a patient's coverage details for the health care services (e.g., laboratory or imaging services, hospitalizations, surgical procedures.)

Medical Necessity

Process of providing diagnosis codes that support the services rendered to the patient; coding for the medical necessity involves associating applicable diagnosis codes to the service/procedure codes within the billing software, which is referred to as linking/linkage

Preauthorization

Process of requesting approval for a service or procedure by providing medical history to the insurance to support the medical need for the service/procedure

Eligibility

Process of verifying the patient has insurance coverage and has benefits for the services to be provided.

Revenue Cycle Management

Process that health care providers use to manage financial viability by increasing revenue, improving cash flow, from registration to final payment.

Accounts Receivable

The amount owed to a provider for health care services rendered.

Encounter Form

Document that captures diagnosis or procedure codes for the services provided during the patient's encounter (electronic or paper format)

Covered Entity

Entity that transmits health information is electronic form (e.g., providers, health plans, clearing houses)

Health Insurance Portability and Accountability Act (HIPAA)

Federal act that governs and mandates regulations that include privacy, confidentiality, and security for health care data and information.

Copayment

Flat, fixed amount that a patient pays for specific services (e.g., office or emergency department encounters).

Third Party Payer

Health care insurance company that reimburses services provided by providers and/or health care organizations.