concurrent care
medical assistance given to a patient who receives independent care from two or more physicians on the same date
suspended
claim status when the payer is developing the claim
development
process of gathering information to adjudicate a claim
determination
payer's decision about the benefits due for a claim
medical necessity denial
refusal by a plan to pay for a procedure that doers not meet its medical necessity criteria
remittance advice (RA)
document describing a payment resulting from a claim adjudication
HIPAA X12 835 Heal Care Payment and Remittance Advice (HIPAA 835)
electronic transaction for payment explanation
explanation of benefits
document showing a beneficiary how the amount of a benefit was determined
claim turnaround time
time period in which a health plan must process a claim
prompt-pay laws
state laws obligating carriers to pay clean claims within a certain time period
aging
classification of accounts receivable by length of time
insurance aging report
report grouping unpaid claims transmitted to payers by the length of time they remain due
HIPAA X12 276/277 Health Care Claim Status Inquiry/Response (HIPAA 276/277)
standard electronic transaction to obtain information on the status of a claim
claim status category codes
codes used on a HIPAA 277 to report the status group for a claim
pending
claim status when the payer is waiting for information
claim status codes
codes used on HIPAA 277 to provide a detailed answer to a claim status inquiry
claim adjustment group code
code used on an RA to indicate the general type of reason code for an adjustment
claim adjustment reason code (CARC)
code used on an RA to explain why a payment does not match the amount billed
remittance advice remark code (RARC)
code that explains payers' payment decisions
Medicare Outpatient Adjudication (MOA) remark codes
codes that explain Medicare payment decisions
electronic funds transfer (EFT)
electronic routing of funds between banks
autoposting
software feature enabling automatic entry of payments on a remittance advice
reconciliation
comparison of two numbers
appeal
request for reconsideration of a claim adjudication
claimant
person/entity exercising the right to receive benefits
appellant
one who appeals a claim decision
redetermination
first level of Medicare appeal processing
Medicare Redetermination Noice (MRN)
communication of the resolution of a first appeal for Medicare fee-for-service claims
overpayments
improper or excessive payments resulting from billing errors
Medicare Secondary Payer (MSP)
federally mandated program requiring private payers to be the primary payers for Medicare beneficiaries' claims