NHA./CBCS./Study./Guide!
1. Adjudication:./The./process./where./the./insurance./company./receives./a./claim./and./makes./a./determination./o
n./payment./or./denial.
2. Allowed./Amount:./The./maximum./amount./an./insurance./company./will./pay./for./the./service,./procedure,./o
r./supply.
3. Auditing./Process:./The./act./of./reviewing./and./comparing./the./patient./medical./records./and./claims./to./asses
s./for./coding./appropriateness./and./completeness./of./the./medical./documentation.
4. Coding. / Compliance:. / The./conformity./and./adherence./to./established./coding./guidelines./and./regulations
.
5. Current./Procedural./Terminology./(CPT):./Descriptive./definitions./used./to./explain./procedures./and./
services./provided./to./the./patient.
6. Denied. / Claim:. / A./claim./returned./from./a./third-
party./payer./because./of./technical./errors./or./patient./coverage./errors.
7. Explanation./of./Benefits./(EOB):./Document./that./explains./how./the./payer./processed./the./claim./for
./services./rendered;./can./also./be./referred./to./as./remittance./advice./(RA).
8. Fee-for-Service:. / Cost./or./fee./that./is./charged./for./each./individual./service.
9. Health./and./Human./Services:./Government./department./that./oversees./the./health./of./the./community
./and./provides./crucial./services.
10. International. / Classification. / of. / Diseases,. / Tenth. / revision,. / Clinical. / Modification.
/(ICD-10-
CM):./List./of./codes./used./to./report./and./classify./diseases,./conditions./and./other./reasons./for./health./care./enco
unters.
11. Noncompliance:./The./act./of./disregarding./rules./and./guidelines./outlined./by./state./and./federal./governme
nt./agencies./and./third-party./payers.
12. Office. / of. / Inspector. / General. / (OIG):. / Government./department./that./investigates./fraud./and./abuse.
13. Place. / of. / Service. / (POS). / Code:. / Two-digit./code./that./identifies./where./the./services./were./performed.
14. Abuse:./Billing./patterns./and./practices./that./are./excessive./or./unnecessary./but./not./fraudulent../-
./When./the./provider./unknowingly./or./unintentionally./misrepresented./information./on./a./claim./for./reimbursement.
15. Accounts. / Receivable:. / The./amount./owed./to./a./provider./for./health./care./services./rendered.
16. Appeals./Process:./A./process./used./to./request./review./of./a./claim./that./was./denied---
to./determine./if./the./denial./was./due./to./a./billing./error;./if./so,./correct./it;./file./an./appeal./at./the./lowest./level;./and./then./m
ove./up./to./higher./levels./if./needed.
17. Assignment./of./Benefits:. / Method./of./a./patient./requesting./their./claim./benefits./be./paid./to./the./health./car
, NHA./CBCS./Study./Guide!
e./organization./that./provided./the./service.
18. Beneficiary:. / Person./eligible./to./receive./benefits./for./covered./health./care./services./rendered.
, NHA./CBCS./Study./Guide!
19. Coinsurance:. / Predetermined./percentage./the./patient./is./responsible./to./pay./for./covered./services./once./
the./annual./deductible./has./been./met.
20. Copayment./(copay):./Flat,./fixed./amount./that./a./patient./pays./for./specific./services./(e.g.,./oflce./or./Emergency./
Department./encounters)..///./Many./policies./have./a./$25./copay./for./PCP./oflce./visits./and./$35-
$50./copay./for./specialists)
21. Covered./Entity:./Entity./that./transmits./health./information./in./electronic./form./(e.g.,./providers,./health./plans,
. / clearinghouses)
22. Deductible:. / The./annual./amount./the./patient./must./pay./before./the./insurance./will./begin./to./pay./for./cove
red./benefits.
23. Electronic./Data./Interchange./(EDI):./Computer./technology./that./contains./the./exchange./of./data.
/between./the./health./care./provider./and./payer.
24. Eligibility:./Process./of./verifying./the./patient./has./insurance./coverage./and./has./benefits./for./the./services./to./be
. / provided.
25. Encounter./form:./Document./that./captures./diagnoses./or./procedure./codes./for./the./services./provided./durin
g./the./patient's./encounter./(electronic./or./paper./format).
26. Fraud:./Intentionally./billing./for./services./not./performed,./reporting./fraudulent./diagnoses,./or./medical./coding./er
rors../-
./Intentionally./expecting./a./payment./on./a./claim./when./the./provider./is./aware./of./wrongdoing,./billing./for./services./tha
t./were./not./provided.
27. Health. / Insurance. / Portability. / and. / Accountability. / Act. / of. / 1996. / (HIPAA):. / Feder
al./act./that./governs./and./mandates./regulations./that./include./privacy,./confidentiality,./and./security./for./health./care./da
ta./and./information.
28. Medical. / Necessity:. / Process./of./providing./diagnosis./codes./that./support./the./services./rendered./to./the./p
a-tient;./coding./for./medical./necessity./involves./associating./applicable./diagnosis./codes./(ICD-10-
CM)./to./service/procedure./codes./(CPT)./within./the./billing./software,./which./is./referred./to./as./linking/linkage.
29. Out-of-
Pocket:./Patient./responsibility./portion./of./a./health./insurance./plan./defined./by./the./payer./(includes./annual./
deductible,./copay,./and./coinsurance./amounts).
30. Preauthorization:./The./approval./for./a./service./or./procedure,./and./timely./filing./is./the./time./frame./to./subm
it./a./claim.
31. Precertification:./Process./of./determining./a./patient's./coverage./details./for./health./care./services./(e.g.,./labo
-ratory./or./imaging./services,./hospitalizations,./surgical./procedures).
, NHA./CBCS./Study./Guide!
32. Protected. / Health. / Information. / (PHI):. / Individually./identifiable./patient./information.
33. Revenue./Cycle./Management./(RCM):./Process./that./health./care./providers./use./to./manage./financial
./viability./by./increasing./revenue,./improving./cash./flow,./from./registration./to./final./payment.
1. Adjudication:./The./process./where./the./insurance./company./receives./a./claim./and./makes./a./determination./o
n./payment./or./denial.
2. Allowed./Amount:./The./maximum./amount./an./insurance./company./will./pay./for./the./service,./procedure,./o
r./supply.
3. Auditing./Process:./The./act./of./reviewing./and./comparing./the./patient./medical./records./and./claims./to./asses
s./for./coding./appropriateness./and./completeness./of./the./medical./documentation.
4. Coding. / Compliance:. / The./conformity./and./adherence./to./established./coding./guidelines./and./regulations
.
5. Current./Procedural./Terminology./(CPT):./Descriptive./definitions./used./to./explain./procedures./and./
services./provided./to./the./patient.
6. Denied. / Claim:. / A./claim./returned./from./a./third-
party./payer./because./of./technical./errors./or./patient./coverage./errors.
7. Explanation./of./Benefits./(EOB):./Document./that./explains./how./the./payer./processed./the./claim./for
./services./rendered;./can./also./be./referred./to./as./remittance./advice./(RA).
8. Fee-for-Service:. / Cost./or./fee./that./is./charged./for./each./individual./service.
9. Health./and./Human./Services:./Government./department./that./oversees./the./health./of./the./community
./and./provides./crucial./services.
10. International. / Classification. / of. / Diseases,. / Tenth. / revision,. / Clinical. / Modification.
/(ICD-10-
CM):./List./of./codes./used./to./report./and./classify./diseases,./conditions./and./other./reasons./for./health./care./enco
unters.
11. Noncompliance:./The./act./of./disregarding./rules./and./guidelines./outlined./by./state./and./federal./governme
nt./agencies./and./third-party./payers.
12. Office. / of. / Inspector. / General. / (OIG):. / Government./department./that./investigates./fraud./and./abuse.
13. Place. / of. / Service. / (POS). / Code:. / Two-digit./code./that./identifies./where./the./services./were./performed.
14. Abuse:./Billing./patterns./and./practices./that./are./excessive./or./unnecessary./but./not./fraudulent../-
./When./the./provider./unknowingly./or./unintentionally./misrepresented./information./on./a./claim./for./reimbursement.
15. Accounts. / Receivable:. / The./amount./owed./to./a./provider./for./health./care./services./rendered.
16. Appeals./Process:./A./process./used./to./request./review./of./a./claim./that./was./denied---
to./determine./if./the./denial./was./due./to./a./billing./error;./if./so,./correct./it;./file./an./appeal./at./the./lowest./level;./and./then./m
ove./up./to./higher./levels./if./needed.
17. Assignment./of./Benefits:. / Method./of./a./patient./requesting./their./claim./benefits./be./paid./to./the./health./car
, NHA./CBCS./Study./Guide!
e./organization./that./provided./the./service.
18. Beneficiary:. / Person./eligible./to./receive./benefits./for./covered./health./care./services./rendered.
, NHA./CBCS./Study./Guide!
19. Coinsurance:. / Predetermined./percentage./the./patient./is./responsible./to./pay./for./covered./services./once./
the./annual./deductible./has./been./met.
20. Copayment./(copay):./Flat,./fixed./amount./that./a./patient./pays./for./specific./services./(e.g.,./oflce./or./Emergency./
Department./encounters)..///./Many./policies./have./a./$25./copay./for./PCP./oflce./visits./and./$35-
$50./copay./for./specialists)
21. Covered./Entity:./Entity./that./transmits./health./information./in./electronic./form./(e.g.,./providers,./health./plans,
. / clearinghouses)
22. Deductible:. / The./annual./amount./the./patient./must./pay./before./the./insurance./will./begin./to./pay./for./cove
red./benefits.
23. Electronic./Data./Interchange./(EDI):./Computer./technology./that./contains./the./exchange./of./data.
/between./the./health./care./provider./and./payer.
24. Eligibility:./Process./of./verifying./the./patient./has./insurance./coverage./and./has./benefits./for./the./services./to./be
. / provided.
25. Encounter./form:./Document./that./captures./diagnoses./or./procedure./codes./for./the./services./provided./durin
g./the./patient's./encounter./(electronic./or./paper./format).
26. Fraud:./Intentionally./billing./for./services./not./performed,./reporting./fraudulent./diagnoses,./or./medical./coding./er
rors../-
./Intentionally./expecting./a./payment./on./a./claim./when./the./provider./is./aware./of./wrongdoing,./billing./for./services./tha
t./were./not./provided.
27. Health. / Insurance. / Portability. / and. / Accountability. / Act. / of. / 1996. / (HIPAA):. / Feder
al./act./that./governs./and./mandates./regulations./that./include./privacy,./confidentiality,./and./security./for./health./care./da
ta./and./information.
28. Medical. / Necessity:. / Process./of./providing./diagnosis./codes./that./support./the./services./rendered./to./the./p
a-tient;./coding./for./medical./necessity./involves./associating./applicable./diagnosis./codes./(ICD-10-
CM)./to./service/procedure./codes./(CPT)./within./the./billing./software,./which./is./referred./to./as./linking/linkage.
29. Out-of-
Pocket:./Patient./responsibility./portion./of./a./health./insurance./plan./defined./by./the./payer./(includes./annual./
deductible,./copay,./and./coinsurance./amounts).
30. Preauthorization:./The./approval./for./a./service./or./procedure,./and./timely./filing./is./the./time./frame./to./subm
it./a./claim.
31. Precertification:./Process./of./determining./a./patient's./coverage./details./for./health./care./services./(e.g.,./labo
-ratory./or./imaging./services,./hospitalizations,./surgical./procedures).
, NHA./CBCS./Study./Guide!
32. Protected. / Health. / Information. / (PHI):. / Individually./identifiable./patient./information.
33. Revenue./Cycle./Management./(RCM):./Process./that./health./care./providers./use./to./manage./financial
./viability./by./increasing./revenue,./improving./cash./flow,./from./registration./to./final./payment.
