Term
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Definition
| associated with how an insurance plan is billed — the insurance plan responsible for pay¬ing health care insurance claims first is considered primary. |
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Term
Provider Remittance Notice (PRN) |
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Definition
| remittance advice submitted by Medicare to providers that includes payment information about a claim. |
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Term
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Definition
| Provider Remittance Notice |
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Term
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Definition
| any procedure or service reported on a claim that is not included on the payer's master benefit list, resulting in denial of the claim; also called noncovered procedure or uncovered benefit. |
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Term
nonparticipating provider (nonPAR)
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Definition
| does not contract with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses. |
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Term
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Definition
| nonparticipating provider |
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Term
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Definition
| submitted to the payer, but processing is not complete. |
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Term
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Definition
| legal action to recover a debt; usually a last resort for a medical practice. |
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Term
manual daily accounts receivable journal |
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Definition
| also called the day sheet; a chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day. |
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Term
| Fair Credit and Charge Card Disclosure Act |
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Definition
| amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-end credit and charge accounts and under other circumstances; this law applies to providers that accept credit cards. |
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Term
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Definition
| federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory goods and services; cardholders cannot be held liable for more than $50 of fraudulent charges made to a credit card. |
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Term
Fair Credit Reporting Act |
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Definition
| protects information collected by consumer reporting agencies such as credit bureaus, medical information companies and tenant screening services; organizations that provide information to consumer reporting agencies also have specific legal obligations, including the duty to investigate disputed information. |
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Term
Fair Debt Collection Practices Act (FDCPA) |
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Definition
| specifies what a collection source may and may not do when pursuing payment of past due accounts. |
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Term
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Definition
| Fair Debt Collection Practices Act |
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Term
Equal Credit Opportunity Act |
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Definition
| prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good faith exercise of any rights under the Consumer Credit Protection Act. |
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Term
| electronic flat file format |
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Definition
| series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers to bill for health care services |
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Term
electronic funds transfer (EFT) |
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Definition
| system by which payers deposit funds to the provider's account electronically. |
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Term
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Definition
| electronic funds transfer |
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Term
Electronic Funds Transfer Act |
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Definition
| established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems |
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Term
Electronic Healthcare Network Accreditation Commission (EHNAC) |
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Definition
| organization that accredits clearinghouses. |
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Term
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Definition
| Electronic Healthcare Network Accreditation Commission |
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Term
electronic remittance advice (ERA) |
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Definition
| remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly. |
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Term
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Definition
electronic remittance advice |
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Term
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Definition
| private sector health plans (exclud¬ing 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 (includ¬ing 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 pro¬viders that choose to submit or receive transactions electronically. |
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Term
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Definition
| assigning lower-level codes than documented in the record. |
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Term
coordination of benefits (COB) |
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Definition
| 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. |
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Term
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Definition
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Term
Consumer Credit Protection Act of 1968 |
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Definition
| 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. |
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Term
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Definition
| also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day. |
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Term
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Definition
| claim usually more than 120 days past due; some practices establish time frames that are less than or more than 120 days past due. |
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Term
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Definition
| advances through various aging periods (30 days, 60 days, 90 days, and so on), with practices typically focusing internal recovery efforts on older delinquent accounts (e.g., 120 days or more). |
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Term
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Definition
| financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. |
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Term
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Definition
| person responsible for paying health care fees. |
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Term
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Definition
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Term
participating provider (PAR) |
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Definition
| contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. |
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Term
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Definition
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Term
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Definition
| one that has not been paid within a certain time frame (e.g., 120 days); also called delinquent account. |
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Term
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Definition
| also called patient ledger; a computerized permanent record of all financial transactions between the patient and the practice. |
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Term
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Definition
| established by health insurance companies for a health insurance plan; usually has limits of $1,000 or $2,000; when the patient has reached the limit of an out-of-pocket payment (e.g., annual deductible) for the year, appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision. |
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Term
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Definition
| any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage. |
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Term
| value-added network (VAN) |
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Definition
| clearinghouse that involves value-added vendors, such as banks, in the processing of claims; using a VAN is more efficient and less expensive for providers than managing their own systems to send and receive transactions directly from numerous entities |
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Term
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Definition
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Term
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Definition
| generated for providers who do not accept assignment; organized by year. |
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Term
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Definition
| services that are provided to a patient without proper authorization or that are not covered by a current authorization. |
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Term
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Definition
| submitting multiple CPT codes when one code should be submitted. |
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Term
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Definition
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Term
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Definition
| check made out to both patient and provider. |
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Term
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Definition
| person responsible for paying health care fees. |
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Term
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Definition
| claims for which all processing, includ¬ing appeals, has been completed. |
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Term
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Definition
| use a variable-length file format to process transactions for institutional, profes¬sional, dental, and drug claims. |
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Term
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Definition
| documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. |
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Term
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Definition
| the provider receives reim¬bursement directly from the payer. |
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Term
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Definition
| the person eligible to receive health care benefits. |
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Term
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Definition
| determines coverage by primary secondary policies when each parent subscribes different health insurance plan. |
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Term
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Definition
| provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts). |
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Term
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Definition
| the amount owed to a business for services or goods provided. |
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Term
accounts receivable aging report |
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Definition
| shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. |
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Term
| accounts receivable management |
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Definition
| assists providers in the collection of appropriate reimbursement for services rendered; include functions such as insur¬ance verification/eligibility and preauthorization of services. |
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Term
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Definition
| the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy. |
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Term
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Definition
| term hospitals use to describe a patient encounter form. |
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Term
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Definition
| 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 proce¬dures have been followed, and procedures performed or services provided are covered benefits. |
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Term
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Definition
| medical report substantiating a medical condition. |
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Term
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Definition
| sorting claims upon submission to collect and verify information about the patient and provider. |
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Term
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Definition
| the transmission of claims data (electronically or manually) to payers or clearinghouses for processing. |
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Term
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Definition
| a correctly completed standardized claim (e.g., CMS-1500 claim). |
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Term
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Definition
| performs centralized claims processing for providers and health plans. |
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Term
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Definition
| also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid. |
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Term
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Definition
| abstract of all recent claims filed on each patient. |
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