AMBA CMRS flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Coordination of Benefits

The process that determines the order in which multiple health plans pay a claim, preventing duplicate payment and establishing primary, secondary, and tertiary responsibility.

Medicare Secondary Payer

Rules under which Medicare pays after another payer, such as an employer group health plan based on current employment with 20 or more employees.

Advance Beneficiary Notice

A written notice given to a Medicare beneficiary before a service likely to be denied as not medically necessary, allowing the provider to bill the patient.

Real-Time Eligibility

An electronic 270/271 transaction that verifies a patient's active coverage, benefits, copay, and deductible before or at the point of service.

Modifier 25

A CPT modifier indicating a significant, separately identifiable evaluation and management service was performed by the same provider on the same day as a procedure.

NCCI Edits

National Correct Coding Initiative edits that identify code pairs not generally billable together, with Column 1 and Column 2 designations and modifier indicators.

Medical Decision Making

One of two bases for selecting an office E/M level under current rules, scored by problem complexity, data review, and risk of complications.

Global Surgical Package

A bundled payment covering preoperative, intraoperative, and postoperative care for a defined period, with modifiers handling exceptions such as staged or unrelated procedures.

Clean Claim Rate

The percentage of claims accepted on first submission without rejection or rework, calculated as clean claims divided by total claims submitted.

CMS-1500 Form

The standard paper claim form used for professional services, corresponding to the 837P electronic transaction under HIPAA.

Timely Filing Limit

The payer-defined deadline, commonly 90 to 180 days from service or discharge, after which a claim is denied as untimely and payment is forfeited.

Claim Frequency Code

A code on an institutional claim indicating whether it is an original (1), replacement (7), or void/cancel (8) submission.

DRG Payment

Inpatient hospital reimbursement calculated by multiplying the diagnosis-related group relative weight by the hospital base rate, with possible adjustments.

Allowed Amount

The maximum amount a payer will recognize for a service, equal to the lesser of the billed charge or the contracted fee schedule rate.

Contractual Adjustment

The difference between billed charges and the allowed amount, written off by the provider and not billable to the patient.

Case-Mix Index

A measure of the average diagnosis-related group weight of a hospital's inpatient population, reflecting resource intensity and driving expected reimbursement.

CARC and RARC

Claim Adjustment Reason Codes and Remittance Advice Remark Codes that appear on the 835 remittance and explain why a claim or line was denied or adjusted.

Medicare Redetermination

The first level of Medicare appeal, filed with the Medicare Administrative Contractor, generally within 120 days of the remittance advice.

Peer-to-Peer Review

A discussion between the treating and payer physician that can overturn a medical necessity denial before or during the formal appeal process.

Denial Rate

The number of denied claims divided by total claims submitted, tracked by root cause to identify preventable front-end and coding failures.

Days in Accounts Receivable

Total accounts receivable divided by total charges, multiplied by the number of days in the period, indicating how long receivables take to convert to cash.

Net Collection Rate

Payments received divided by charges minus contractual adjustments, measuring how effectively the organization collects what it is owed.

A/R Aging Buckets

Segments of receivables by age, typically 0-30, 31-60, 61-90, 91-120, and 120+ days, with older balances carrying higher collection risk.

Small Balance Write-Off

A policy that sets a dollar threshold below which the cost of pursuing a balance exceeds the expected recovery, so it is written off.

Copay versus Coinsurance

A copay is a fixed dollar amount per service, while coinsurance is a percentage of the allowed amount that the patient owes.

Financial Assistance Policy

A written policy, required for tax-exempt hospitals, defining income-based eligibility for discounted or free care, often tied to the federal poverty level.

Good-Faith Estimate

A price transparency requirement providing uninsured or self-pay patients an advance estimate of expected charges for scheduled services.

Point-of-Service Collection

Collecting known patient responsibility, such as copay or deductible, at the time of service to improve cash flow and reduce bad debt.

Anti-Kickback Statute

A federal criminal statute prohibiting knowing and willful remuneration intended to induce referrals of items or services payable by federal healthcare programs.

Stark Law

A strict-liability civil statute prohibiting physician referrals of designated health services to entities with which the physician has a financial relationship, absent an exception.

OIG Compliance Elements

The seven elements of an effective compliance program, including written policies, a compliance officer, training, auditing, and enforcement and discipline.

Exclusion Screening

Checking the OIG List of Excluded Individuals/Entities and SAM database before hiring or contracting to avoid billing for excluded providers.