| A | B |
|---|
| insurance | a contract that protects the insured against loss |
| 1st party | the patient |
| accept assignment | provider accepts as payment in full whatever the insurance co pays(except copay and co-ins) |
| assignment of benefits | provider receives payment directly from insurance co. |
| benefit | amount predetermined by the insurance carrier, that it will pay for specific claims |
| birthday rule | determines order of billing (primary and secondary polices) when parents subscribe to different insurance plans |
| chargemaster | hospital encounter forms |
| claim attachment | medical report substantiating a medical condition |
| claims adjudication | comparing a claim to payer edits and patient health plan to verify and determine payment |
| claims processing | sorting claims to collect and verify information about patient and provider |
| claims submission | transmission of claims to payers or clearinghouses for processing |
| clean claim | correctly completed standardized claim |
| CMS | Centers for Medicare & Medicaid services |
| CMS-1500(HCFA-1500) | Form used to submit medical claims |
| COB | coordination of benefits |
| coinsurance | % the patient pays after deductible has been met |
| copay | amount patient must pay for each visit |
| CPT | current procedural terminology codes for procedures & services performed |
| deductible | amount patient must pay before ins co pays |
| dependent | someone other than the subscriber who is covered under the subscriber's policy |
| disability | reimbursement for income lost |
| encounter form | superbill |
| EOB | explantion of benefits |
| fee schedule | list of predetermined payments for health care services |
| gatekeeper | PCP |
| group health insurance | health care coverage available through employers or other organizations. Employers of the organization usually pays part of the premium |
| guarantor | person responsible for payment |
| ICD-9-CM | international classification of diseases 9th revision clinical modification |
| liability | covers losses to a third party caused by the insured, by an object owned by the insured or on the premises of the insured |
