Certified Revenue Cycle Specialist
1-Day and 3-Day Payment Window Rule - ANS-The 3-day payment rule is a Medicare
regulation that requires all diagnostic and clinically related non-diagnostic outpatient services
provided within three days of an inpatient admission to be combined to the inpatient claim
when they are provided by an entity wholly owned or operated by the inpatient hospital.
The 1 day payment window applies to certain hospitals like inpatient psychiatric,
rehabilitation, long term care, children's and cancer hospitals.
ABN - ANS-Advanced Beneficiary Notice of Non-coverage - when a service does not meet
or is not expected to meet medical necessity, the beneficiary must sign an ABN
acknowledging that Medicare will not or probably will not cover the specific item. Must be
kept on file for 5 years from discharge.
ABN Triggering Events - ANS-1. Initiation of services
2. Reduction of services
3. Termination of services
Abuse - ANS-incidents or practices of healthcare workers that, although not usually
considered fraudulent, are inconsistent with accepted sound practices (ie excessive or
unwarranted use of technology and services)
ACF - ANS-Administration for Children and Families
ACL - ANS-Administration for Community Living
administrative sanctions for fraudulent provider behavior - ANS-1. denial/revocation of
provider number application
2. suspension of provider payments
3. application of civil monetary penalties (CMP)
AHA - ANS-American Hospital Association - Patient Care Partnership brochure, formerly
known as Patient's Bill of Rights
ALOS - ANS-average length of stay - calculated by dividing the total number of patient days
by the number of discharges
ATSDR - ANS-Agency for Toxic Substances and Disease Registry
Average Daily Revenue - ANS-the average amount of revenue or charges generated each
day over a specified period of time.
sum of revenue / number of days
Average Days of Revenue in Accounts Receivable (ADRR) - ANS-Also known as Accounts
Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the
days required to turn over the accounts receivable under normal operating conditions; in
simple terms, this is an estimate of the time needed to collect the accounts receivable.
AR at specific time / average daily revenue
CAH - ANS-Critical Access Hospital - rural hospitals that must maintain no more than 25
inpatient beds, must be located more than 35 mile drive from any hospital in mountainous
terrain or secondary roads.
, Capitation - ANS-method of payment in which a provider is paid a set dollar amount for each
patient for a specific time period
CDC - ANS-Centers for Disease Control and Prevention
Chargemaster - ANS-electronic file that resides in provider's information system and that
contains charges that can be posted to a patient account.
Charity care, Indigent and bad debt - ANS-Charity care is a service provided that is never
expected to result in cash flow.
Indigent is an individual who has no means of paying for medical services.
Bad debt is an uncollectible account resulting from extension of credit.
Clean Claim - ANS-One which does not require carrier or MAC to investigate or develop
external to their medicare operation on a prepayment basis - passes common working file
edits, filed electronically, has all necessary information to adjudicate the claim
CLIA - ANS-Clinical Laboratory Improvement Amendment - requires all clinical laboratory
services furnished to medicare beneficiaries must be performed by provider with CLIA
certificate.
CMS - ANS-Centers for Medicare and Medicaid Services
CMS-1500/837P form - ANS-The billing form used to submit physician and professional
service claims
Condition code - ANS-Two digit code that identifies the condition(s) relating to the bill that
may affect payer processing - ie information only, benificiary would not provide info about
other ins coverage, billing for denial notice.
CWF - ANS-Common Working File - Contains Medicare patient eligibility and utilization data
Data mailer/statement - ANS-A system generated, free-form statement that is used to
communicate the status of a patient's account/ to bill the patient for an unpaid amount
remaining on the account.
Definitive vs Non-definitive NCD/LCD - ANS-1. Definitive: one where the NCD/LCD gives
specific diagnosis and procedure codes, or signs and symptoms to support the need for a
service.
2. Non-definitive: one where there is only potential coverage circumstances, but does not
provide specific diagnosis codes that will be covered or not covered. Usually a medical
record is required for coverage determination to be made.
DNR - ANS-do not resuscitate order
ECOA - ANS-Equal Credit Opportunity Act - prohibits credit discrimination based on race,
color, religion, national origin, sex, martial status, age, or because someone receives public
assistance.
EMTALA - ANS-Emergency Medical Treatment and Active Labor Act - anti-dumping law that
stops hospitals from refusing to treat patients without insurance, or transferring them to other
facilities. Requires medical exam in ED before asking about intention to pay bill.
ERISA - ANS-Employee Retirement Income Security Act, regulates self insured plans
Explanation of Benefits/Remittance Advice/835 - ANS-A statement sent by a health
insurance company to covered individuals explaining what medical treatments/services were
paid for on their behalf. Remittance advice should have a check attached or voucher for an
electronic payment which was made directly to the provider's bank.
Fair Credit Billing Act - ANS-requires creditors inform debtors of their rights and
responsibilities of the creditor
1-Day and 3-Day Payment Window Rule - ANS-The 3-day payment rule is a Medicare
regulation that requires all diagnostic and clinically related non-diagnostic outpatient services
provided within three days of an inpatient admission to be combined to the inpatient claim
when they are provided by an entity wholly owned or operated by the inpatient hospital.
The 1 day payment window applies to certain hospitals like inpatient psychiatric,
rehabilitation, long term care, children's and cancer hospitals.
ABN - ANS-Advanced Beneficiary Notice of Non-coverage - when a service does not meet
or is not expected to meet medical necessity, the beneficiary must sign an ABN
acknowledging that Medicare will not or probably will not cover the specific item. Must be
kept on file for 5 years from discharge.
ABN Triggering Events - ANS-1. Initiation of services
2. Reduction of services
3. Termination of services
Abuse - ANS-incidents or practices of healthcare workers that, although not usually
considered fraudulent, are inconsistent with accepted sound practices (ie excessive or
unwarranted use of technology and services)
ACF - ANS-Administration for Children and Families
ACL - ANS-Administration for Community Living
administrative sanctions for fraudulent provider behavior - ANS-1. denial/revocation of
provider number application
2. suspension of provider payments
3. application of civil monetary penalties (CMP)
AHA - ANS-American Hospital Association - Patient Care Partnership brochure, formerly
known as Patient's Bill of Rights
ALOS - ANS-average length of stay - calculated by dividing the total number of patient days
by the number of discharges
ATSDR - ANS-Agency for Toxic Substances and Disease Registry
Average Daily Revenue - ANS-the average amount of revenue or charges generated each
day over a specified period of time.
sum of revenue / number of days
Average Days of Revenue in Accounts Receivable (ADRR) - ANS-Also known as Accounts
Receivable (AR) Days Outstanding; an estimate, using average current revenues, of the
days required to turn over the accounts receivable under normal operating conditions; in
simple terms, this is an estimate of the time needed to collect the accounts receivable.
AR at specific time / average daily revenue
CAH - ANS-Critical Access Hospital - rural hospitals that must maintain no more than 25
inpatient beds, must be located more than 35 mile drive from any hospital in mountainous
terrain or secondary roads.
, Capitation - ANS-method of payment in which a provider is paid a set dollar amount for each
patient for a specific time period
CDC - ANS-Centers for Disease Control and Prevention
Chargemaster - ANS-electronic file that resides in provider's information system and that
contains charges that can be posted to a patient account.
Charity care, Indigent and bad debt - ANS-Charity care is a service provided that is never
expected to result in cash flow.
Indigent is an individual who has no means of paying for medical services.
Bad debt is an uncollectible account resulting from extension of credit.
Clean Claim - ANS-One which does not require carrier or MAC to investigate or develop
external to their medicare operation on a prepayment basis - passes common working file
edits, filed electronically, has all necessary information to adjudicate the claim
CLIA - ANS-Clinical Laboratory Improvement Amendment - requires all clinical laboratory
services furnished to medicare beneficiaries must be performed by provider with CLIA
certificate.
CMS - ANS-Centers for Medicare and Medicaid Services
CMS-1500/837P form - ANS-The billing form used to submit physician and professional
service claims
Condition code - ANS-Two digit code that identifies the condition(s) relating to the bill that
may affect payer processing - ie information only, benificiary would not provide info about
other ins coverage, billing for denial notice.
CWF - ANS-Common Working File - Contains Medicare patient eligibility and utilization data
Data mailer/statement - ANS-A system generated, free-form statement that is used to
communicate the status of a patient's account/ to bill the patient for an unpaid amount
remaining on the account.
Definitive vs Non-definitive NCD/LCD - ANS-1. Definitive: one where the NCD/LCD gives
specific diagnosis and procedure codes, or signs and symptoms to support the need for a
service.
2. Non-definitive: one where there is only potential coverage circumstances, but does not
provide specific diagnosis codes that will be covered or not covered. Usually a medical
record is required for coverage determination to be made.
DNR - ANS-do not resuscitate order
ECOA - ANS-Equal Credit Opportunity Act - prohibits credit discrimination based on race,
color, religion, national origin, sex, martial status, age, or because someone receives public
assistance.
EMTALA - ANS-Emergency Medical Treatment and Active Labor Act - anti-dumping law that
stops hospitals from refusing to treat patients without insurance, or transferring them to other
facilities. Requires medical exam in ED before asking about intention to pay bill.
ERISA - ANS-Employee Retirement Income Security Act, regulates self insured plans
Explanation of Benefits/Remittance Advice/835 - ANS-A statement sent by a health
insurance company to covered individuals explaining what medical treatments/services were
paid for on their behalf. Remittance advice should have a check attached or voucher for an
electronic payment which was made directly to the provider's bank.
Fair Credit Billing Act - ANS-requires creditors inform debtors of their rights and
responsibilities of the creditor
