Medical Insurance Chapter 14

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aging
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Classification of accounts receivable by the length of time an account is due
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appeal
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A request sent to a payer for reconsideration of a claim adjudication
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appellant
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One who appeals a claim decision
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autoposting
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Software feature that enables automatic entry of payments on a remittance advice to credit an individual's account
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claim adjustment group codes (GRP)
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Codes used by a payer on an RA/EOB to indicate the general type of reason code for an adjustment
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claim adjustment reason codes (RC)
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Code used by a payer on an RA/EOB to explain why a payment does not match the amount billed
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claimant
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Person or entity exercising the right to receive benefits
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claim status category codes
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Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending
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claim status codes
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Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry
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claim turnaround time
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The time period in which a health plan is obligated to process a claim
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concurrent care
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Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service
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determination
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A payer's decision about the benefits due for a claim
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development
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Payer process of gathering information in order to adjudicate a claim
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electronic funds transfer (EFT)
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Electronic routing of funds between banks
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explanation of benefits (EOB)
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Document sent by a payer to a patient that shows how the amount of a benefit was determined
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grievance
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Right of a medical practice to file a complaint with the state insurance commission if it has been treated unfairly by a payer
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HIPAA X12 835 Health Care Payment + Remittance Advice (HIPAA 835)
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the standard transaction payers use to transmit adjudication details + payments to providers
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insurance aging report
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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
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medical necessity denial
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Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria
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Medicare Outpatient Adjudication remark codes (MOA)
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Remittance advice codes that explain Medicare payment decisions
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HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)
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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
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Medicare Redetermination Notice (MRN)
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Resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal
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Medicare Secondary Payer (MSP)
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Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries' claims
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overpayments
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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
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pending
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Claim status during adjudication when the payer is waiting for information from the submitter
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prompt-pay laws
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Regulations that obligate payers to pay clean claims within a certain time period
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RA/EOB
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Remittance advice/explanation of benefits. Paper document detailing the results of claim adjudication and payment
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reconciliation
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Comparison of two numbers to determine whether they differ
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redetermination
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First level of Medicare appeal processing
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remittance advice (RA)
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Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB)
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remittance advice remark codes (RAR)
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Codes that explain payers' payment decisions
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suspended
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Claim status during adjudication when the payer is developing the claim
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