question

aging

answer

Classification of accounts receivable by the length of time an account is due

question

appeal

answer

A request sent to a payer for reconsideration of a claim adjudication

question

appellant

answer

One who appeals a claim decision

question

autoposting

answer

Software feature that enables automatic entry of payments on a remittance advice to credit an individual's account

question

claim adjustment group codes (GRP)

answer

Codes used by a payer on an RA/EOB to indicate the general type of reason code for an adjustment

question

claim adjustment reason codes (RC)

answer

Code used by a payer on an RA/EOB to explain why a payment does not match the amount billed

question

claimant

answer

Person or entity exercising the right to receive benefits

question

claim status category codes

answer

Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending

question

claim status codes

answer

Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry

question

claim turnaround time

answer

The time period in which a health plan is obligated to process a claim

question

concurrent care

answer

Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service

question

determination

answer

A payer's decision about the benefits due for a claim

question

development

answer

Payer process of gathering information in order to adjudicate a claim

question

electronic funds transfer (EFT)

answer

Electronic routing of funds between banks

question

explanation of benefits (EOB)

answer

Document sent by a payer to a patient that shows how the amount of a benefit was determined

question

grievance

answer

Right of a medical practice to file a complaint with the state insurance commission if it has been treated unfairly by a payer

question

HIPAA X12 835 Health Care Payment + Remittance Advice (HIPAA 835)

answer

the standard transaction payers use to transmit adjudication details + payments to providers

question

insurance aging report

answer

A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days

question

medical necessity denial

answer

Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria

question

Medicare Outpatient Adjudication remark codes (MOA)

answer

Remittance advice codes that explain Medicare payment decisions

question

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)

answer

the standard electronic transaction to obtain information on the current status of a claim during the adjudication process. The inquiry is the HIPAA 276, + the response returned by the payer is the HIPAA 277

question

Medicare Redetermination Notice (MRN)

answer

Resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal

question

Medicare Secondary Payer (MSP)

answer

Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries' claims

question

overpayments

answer

An improper or excessive payment to a provider as a result of billing or claims processing errors for which a refund is owed by the provider

question

pending

answer

Claim status during adjudication when the payer is waiting for information from the submitter

question

prompt-pay laws

answer

Regulations that obligate payers to pay clean claims within a certain time period

question

RA/EOB

answer

Remittance advice/explanation of benefits. Paper document detailing the results of claim adjudication and payment

question

reconciliation

answer

Comparison of two numbers to determine whether they differ

question

redetermination

answer

First level of Medicare appeal processing

question

remittance advice (RA)

answer

Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB)

question

remittance advice remark codes (RAR)

answer

Codes that explain payers' payment decisions

question

suspended

answer

Claim status during adjudication when the payer is developing the claim

Medical Insurance Chapter 14

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