payers decision about the benefits due for a claim

A request for reconsideration of a claim adjudication

The list of drugs covered by an insurance plan is called the formulary

UCR stands for

Span of time during which a policy holder can select or make changes to their benefits - both employer sponsored plans as well as Medicare and Medigap

This is a document sent by the payer to the insured (patient)

This refers to the first level of the Medicare 5 levels of appeal.

Coinsurance is the amount you are required to pay towards your health insurance bill when you file a claim. It is typically expressed as a percentage

When a payer review and reduction of a procedure code to a lower value than that reported by the provider is

This is the form tells Medicare beneficiaries that a specific service is not likely to be reimbursed by the program. Must be signed prior to the service being rendered

classification of accounts receivable by the length of time due. For example 30, 60, 90 days

What term refers to improper or excessive payments resulting from billing areas.

Systematic, logical and consistent recording of a patient's health status in a medical record is call documentation

This refers to a change in a patient's account

This Latin term states that an employer can be held responsbile for an employee's actions.

this denial may result from a lack of clear, correct linkage between a diagnosis and a procedure

This is the practice of selecting a CPT code that will pay more than the actual service performed

Insurance always covers very medical service a patient receives

The acronym PHI is

The system of analyzing conditions or treatments for similar groups of patients used to establish Medicare fees for hospital inpatient care

This term refers to a correctly prepared claim that can be paid by the sytem without human review

If a medical practice thinks it has been treated unfairly by an insurance company, it may file this with the local state insurance commission

Medicare typically pays 85% of the allowed charge for services

This is out patient care that does not require an overnight stay

This refers to the clinician primarily responsible for the care of the patient from the beginning of a hospitalization