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