Claims processing, revenue cycle steps, and insurance reimbursement concepts tested on medical billing certification exams.
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- What is the term for the full set of steps from patient registration through final payment collection in a medical practice?
- The revenue cycle
- What is typically the first step of the revenue cycle?
- Patient scheduling and pre-registration
- What form is used to submit professional (physician) claims to insurance payers?
- CMS-1500
- What form is used to submit institutional (hospital or facility) claims?
- UB-04 (also called CMS-1450)
- What is a clearinghouse in medical billing?
- A third party that checks claims for errors and forwards them electronically to payers
- What is claims adjudication?
- The process a payer uses to review a claim and decide how much to pay
- What document does a payer send to a patient explaining how a claim was processed?
- Explanation of Benefits (EOB)
- What is an ERA in medical billing?
- Electronic Remittance Advice, the electronic version of a payment explanation sent to the provider
- Define "deductible" in health insurance.
- The amount a patient must pay out of pocket before insurance starts paying
- Define "copayment."
- A fixed dollar amount a patient pays at the time of service
- Define "coinsurance."
- The percentage of costs a patient pays after meeting the deductible
- What is prior authorization?
- Approval from the payer required before a service is performed for it to be covered
- What is a superbill?
- An itemized form listing services, diagnoses, and charges used to create a claim
- Define "allowed amount" in insurance reimbursement.
- The maximum amount a payer will pay for a covered service
- What is a write-off in medical billing?
- The portion of a charge a provider agrees not to collect, often the difference between billed and allowed amounts