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166 Cards in this Set
- Front
- Back
Adjudication
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Series of steps that determine whether a claim should be paid
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Clearinghouse
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An organization that receives claims from a provider, checks and prepares them for processing, and transmits them to insurance carriers in a standardized format
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Documentation
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A record of healthcare encounters between the physician and the patient, created by the provider
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Electronic health record (EHR)
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A computerized lifelong healthcare record for an individual that incorporates data from all providers who treat the individual
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Encounter form
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A list of the procedures and diagnoses for a patient's visit
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Health information exchange (HIE)
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A network that enables the sharing of health related information among provider organizations according to nationally recognized standards
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Meaningful use
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The utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system
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Medical documentation and billing cycle
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A ten-step process that results in timely payment for medical services
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Patient-centered medical home (PCMH)
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A model of primary care that provides comprehensive and timely care to patients, while emphasizing teamwork and patient involvement
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Personal health record (PHR)
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A comprehensive record of health information that is created and maintained by an individual over time
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Practice management program (PMP)
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Health information technology applications that facilitate the day-to-day financial operations of a medical practice
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Protected health information (PHI)
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Information about a patient's health or payment for healthcare that can be used to identify the person
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Remittance advice (RA)
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A document that lists the amount that has been paid on each claim as well as the reasons for nonpayment or partial payment
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Revenue cycle management (RCM)
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The process of managing the activities associated with a patient encounter to ensure that the provider receives full payment for services
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Access rights
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An option that determines which areas of the program a user can access and whether the user can only view data or has rights to enter or edit data
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Auto Log Off
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A feature that automatically logs a user out of the program after a specified number of minutes of inactivity
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Backup data
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A copy of data files made at a specific point in time that can be used to restore data to the system
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Database
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A collection of related pieces of information
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MMDDCCYY format
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The way dates must be entered in Medisoft
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Medisoft program date
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The date recorded in Medisoft when a transaction is entered
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Packing data
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The deletion of vacant slots from the database
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Purging data
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The process of deleting files of patients who are no longer seen by a provider in a practice
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Rebuilding indexes
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A process that checks and verifies data and corrects any internal problems with the data
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Recalculating balances
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The process of updating balances to reflect the most recent changes made to the data
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Restoring data
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The process of retrieving data from backup storage devices
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Chart number
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A unique number that identifies a patient
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Office Hours break
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A block of time when a physician is unavailable for appointments with patients
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Office Hours calendar
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An interactive calendar that is used to select or change dates in Office Hours
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Office Hours patient information
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The area of Office Hours window that displays information about the patient who is selected in the provider's daily schedule
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Provider's daily schedule
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A listing of time slots for a particular day for a specific provider that corresponds to the date selected in the calendar
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Provider selection box
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A selection box that determines which provider's schedule is displayed in the provider's daily schedule
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Recall list
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A list of patients who need to be contacted for future appointments
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Established patient
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A patient who has been seen by a provider in the practice in the same specialty or subspecialty within three years
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Guarantor
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An individual who may not be a patient of the practice but who is financially responsible for a patient account
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New patient
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A patient who has not received services from the same provider or a provider of the same specialty or subspecialty within the same practice for a period of three years
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Capitated plan
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An insurance plan in which payments are made to primary care providers whether patients visit the office or not
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Case
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A grouping of transactions organized around a common element
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Crossover claims
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Claims that are processed by Medicare and then transferred to Medicaid, or to a payer that provides supplemental insurance benefits to Medicare beneficiaries
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Primary insurance carrier
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The insurance company that receives claims before they are submitted to any payer
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Progress notes
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Physician's notes about a patient's condition and diagnosis
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Referring provider
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A physician who recommends that a patient make an appointment with a particular doctor
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Sponsor
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The active-duty service member on the TRICARE government insurance program
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Adjustments
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Portion of the bill that the insurance company will write off as non-allowable and cannot be collected
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Charges
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The amounts billed by a provider for particular services
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MultiLink Codes
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Groups of procedure code entries that are related to a single activity
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NSF check
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A payment not honored by a bank because the account it was written on does not have sufficient funds to cover the check
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Payments
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Monies paid to a medical practice by patients and insurance carriers
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Walkout receipt
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A receipt given to the patient after a payment is made that lists the procedures, diagnosis, charges, and payment
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Capitation
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Private or government organization that insures or pays for healthcare
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Capitation
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A fixed amount that is paid to a provider to provide medically necessary services to patients
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Clean claims
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Healthcare claims with all the correct information necessary for payer processing
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CMS-1500
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The mandated paper insurance claim form
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Point-of-service (POS) plan
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A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network
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Preferred provider organization (PPO)
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A network of healthcare providers who agree to provide services to plan members at a discounted fee
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x12 837 Health Care Claim or Equivalent Encounter Information (837P)
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The electronic form of the claim used by physician offices to bill for services
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Autoposting
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The automatic posting of data in the remittance advice yo a practice management program
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Capitation payments
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Payments made to physicians on a regular basis (such as monthly) fir providing services to patients in a managed care insurance plan
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Cycle billing
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A type of billing in which patients are divided into groups and statement printing and mailing are staggered throughout the month
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Electronic funds transfer (EFT)
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The electronic movement of monies from one bank account to another
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Electronic remittance advice (ERA)
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An electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier
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Fee schedule
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A document that specifies the amount the provider will be paid for each procedure
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Once-a-month billing
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A type of billing in which statements are mailed to all patients at the same time each month
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Coinsurance
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Percentage of charges that an insured must pay for healthcare services after payment of the deductible amount
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Patient statement
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A list of the amount of money s patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
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Payment schedule
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A document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement
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Remainder statements
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Statements that list only those charges that are not paid in full after all insurance carrier payments have been received
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Standard statements
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Statement that shows all charges regardless of whether the insurance has paid on the transactions
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Accounts receivable
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Monies that are coming into the practice
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Aging report
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A report that lists the amount of money owed the practice, organized by the length of time the money has been owed
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Day sheet
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A report that provides information on practice activities for a twenty-four hour period
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Insurance aging report
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A report that lists how long a payer has taken to respond to insurance claims
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Patient aging report
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A report that lists a patient's balance by age, date, and the amount of the last payment
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Patient day sheet
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A summary of the patient activity on a given day
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Copayment
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A small fee paid by the patient at the time of an office visit
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Patient ledger
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A report that lists the financial activity in each patient's account, including charges, payments, and adjustments
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Payment day sheet
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A report that lists payments received on a given day, organized by provider
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Practice analysis report
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A report that analyzes the revenue of a practice for a specified period of time, usually a month or year
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Procedure day sheet
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A report that lists the procedures performed on a given day, listed in numerical order
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Collection agency
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An outside firm hired to collect on delinquent accounts
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Collection list
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A tool for tracking activities that need to be completed as part of the collection process
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Collection tracer report
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A tool for tracking collection letters that were sent
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Payment plan
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An agreement between a patient and a practice in which the patient agrees to make regular monthly payments over a specified period of time
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Prompt payment laws
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Legislation that mandates a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer
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Tickler
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A reminder to follow up on an account
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Deductible
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The amount a policyholder must spend on medical services before benefits begin
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Timely filing
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A time period within which claims must be filed with an insurance carrier
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Uncollectible amount
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An account that does not respond to collection efforts and is written off the practice's expected accounts receivable
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Write-off
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A balance that is removed from a patient's account
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Health maintenance organization (HMO)
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A type of managed care system in which providers are paid fixed rates at regular intervals
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High-deductible health plan with savings option (HDHP/SO)
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A type of managed care insurance in which a high-deductible plan is combined with s pre-tax savings account to cover out-of-pocket medical expenses
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Indemnity plan
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An insurance plan in which policyholders are reimbursed for healthcare costs
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Managed care
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A type if insurance in which the carrier is responsible for the financing and delivery of healthcare
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Medical necessity
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Healthcare services that are reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care
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Payer
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Private or government organization that insures or psys for heslthcare
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CMS-1500
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The mandated paper insurance claim form
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Point-of-service (POS) plan
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A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network
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Copayment
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A fixed amount paid by the patient at the time of an office visit
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x12 837 Health Care Claim or Equivalent Encounter Information (837P)
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The electronic form of the claim used by physician offices to bill for services
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Autoposting
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The automatic posting of data in the remittance advice yo a practice management program
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High-deductible health plan with savings option (HDHP/SO)
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A type of managed care insurance in which a high-deductible plan is combined with a pre-tax savings account to cover out-of-pocket medical expenses
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Cycle billing
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A type of billing in which patients are divided into groups and statement printing and mailing are staggered throughout the month
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Managed care
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A type of insurance in which the carrier is responsible for the financing and delivery of healthcare
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Electronic remittance advice (ERA)
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An electronic document that lists patients, dates of service, charges, and the amount paid or denied by the insurance carrier
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Payer
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Private or government organization that insures or pays for healthcare
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Once-a-month billing
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A type of billing in which statements are mailed to all patients at the same time each month
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Coinsurance
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Percentage of charges that an insured must pay for healthcare services after payment of the deductible amount
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Patient statement
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A list of the amount of money s patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
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Autoposting
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The automatic posting of data in the remittance advice to a practice management program
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Capitation payments
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Payments made to physicians on a regular basis (such as monthly) for providing services to patients in a managed care insurance plan
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Standard statements
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Statement that shows all charges regardless of whether the insurance has paid on the transactions
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Accounts receivable
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Monies that are coming into the practice
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Aging report
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A report that lists the amount of money owed the practice, organized by the length of time the money has been owed
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Day sheet
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A report that provides information on practice activities for a twenty-four hour period
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Insurance aging report
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A report that lists how long a payer has taken to respond to insurance claims
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Patient statement
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A list of the amount of money a patient owes, organized by the amount of time the money has been owed, the procedures performed, and the dates the procedures were performed
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Payment schedule
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A document that specifies the amount the payer agrees to pay the provider for a service, based on a contracted rate of reimbursement
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Copayment
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A small fee paid by the patient at the time of an office visit
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Patient ledger
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A report that lists the financial activity in each patient's account, including charges, payments, and adjustments
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Payment day sheet
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A report that lists payments received on a given day, organized by provider
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Practice analysis report
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A report that analyzes the revenue of a practice for a specified period of time, usually a month or year
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Procedure day sheet
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A report that lists the procedures performed on a given day, listed in numerical order
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Collection agency
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An outside firm hired to collect on delinquent accounts
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Collection list
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A tool for tracking activities that need to be completed as part of the collection process
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Collection tracer report
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A tool for tracking collection letters that were sent
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Payment plan
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An agreement between a patient and a practice in which the patient agrees to make regular monthly payments over a specified period of time
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Prompt payment laws
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Legislation that mandates a time period within which clean claims must be paid; if they are not, financial penalties are levied against the payer
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Tickler
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A reminder to follow up on an account
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Deductible
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The amount a policyholder must spend on medical services before benefits begin
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Timely filing
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A time period within which claims must be filed with an insurance carrier
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Uncollectible amount
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An account that does not respond to collection efforts and is written off the practice's expected accounts receivable
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Write-off
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A balance that is removed from a patient's account
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Health maintenance organization (HMO)
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A type of managed care system in which providers are paid fixed rates at regular intervals
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High-deductible health plan with savings option (HDHP/SO)
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A type of managed care insurance in which a high-deductible plan is combined with s pre-tax savings account to cover out-of-pocket medical expenses
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Indemnity plan
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An insurance plan in which policyholders are reimbursed for healthcare costs
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Managed care
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A type if insurance in which the carrier is responsible for the financing and delivery of healthcare
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Medical necessity
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Healthcare services that are reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care
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Payer
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Private or government organization that insures or psys for heslthcare
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Precertification
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Calling the insurance company to ensure the procedure is a covered expense
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Precertification
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Calling the insurance company to ensure the procedure is a covered expense
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Preauthorization
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Calling the insurance company to see if the procedure is medically necessary
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Precertification
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Calling the insurance company to ensure the procedure is a covered expense
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Preauthorization
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Calling the insurance company to see if the procedure is medically necessary
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Predetermination
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Calling the insurance company to see the dollar amount authorized as the allowable amount
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Coordination of benefits
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Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
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Coordination of benefits
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Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
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Birth day law rule
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Only deals with dependent children; determined by which parent was born first within calendar year (M & D)
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Coordination of benefits
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Involves two insurances; prevents the overlapping of policies so that a claim is only paid at 100%; coordinate to know who to bill first and why; Medicaid is always last to pay
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Birth day law rule
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Only deals with dependent children; determined by which parent was born first within calendar year (M & D)
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EOB
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Explanation of benefits consists of patient's name & info (SS#, BD), provider info (Dr. name), date of service, procedure code, amount billed, amount allowed, amount applied to deductible, copay/coinsurance, amount paid to provider, reason code
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Medicaid
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State funded program for indigent
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Medicaid
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State funded program for indigent
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Medicare
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State/federally funded program acquired if one is handicapped, age 65 or older, suffers End Stage Renal Disease, or Black Lung Disease
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Allowable
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Maximum amount the insurance will pay for a charge
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Allowable
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Maximum amount the insurance will pay for a charge
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Copayment
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Fixed amount a patient pays at each visit
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Allowable
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Maximum amount the insurance will pay for a charge
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Copayment
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Fixed amount a patient pays at each visit
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Coinsurance
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The percentage of the allowable to be paid by the patient
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Deductible
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The out-of-pocket expense to be paid by the patient before the insurance will pay
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Premium
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The amount one pays to have insurance
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Confidentiality
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Ensuring the privacy of a patient's medical records and other health information by safeguarding with limits on the use and access of this information without patient authorization
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CPT
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Current Procedural Terminology; all the procedures that we do to the people
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CPT
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Current Procedural Terminology; all the procedures that we do to the people
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ICD-9-CM
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International Classification of Disease - 9th Edition; what is wrong with the person
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Assignment of benefits
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Giving doctor permission to treat and giving insurance company permission to pay doctor
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Encounter form
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List of all diagnoses and procedure codes; superbill, charge slip, routing slip
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