AMBA CMRS key terms

A written notice a provider gives a Medicare patient before delivering a service that Medicare is expected to deny as not medically necessary, so the patient accepts financial responsibility if they choose to proceed.

The electronic process of confirming a patient's insurance coverage and benefits with the payer before or at the point of service, typically using the HIPAA 270 inquiry and 271 response transactions.

The rules that determine which of a patient's multiple insurance plans pays first, second, or last, preventing duplicate payment and establishing how secondary plans consider the primary plan's payment.

The insurance plan that processes and pays a claim first when a patient is covered by more than one plan, before any secondary coverage is considered.

An insurance plan that reviews a claim after the primary plan has paid, covering remaining balances such as coinsurance or deductible according to its own rules.

The portion of charges a patient personally owes after insurance processing, including copayments, coinsurance, deductible amounts, and services excluded from coverage.

A fixed dollar amount a patient pays at the time of service for a covered benefit, such as a set fee per office visit, regardless of the total charge.

The percentage share of allowed charges a patient owes after the deductible is met, with the insurer paying the remaining percentage per the benefit plan.

The amount a patient must pay out of pocket for covered services each benefit period before the insurance plan begins to pay its share.

The practice of collecting estimated patient balances, such as copays or prior-balance payments, at the time care is delivered to reduce later accounts receivable.

The determination that a service, procedure, or supply is reasonable and required to diagnose or treat a patient's condition according to accepted standards and payer policy.

A standardized code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services and is used to report procedures on claims.

A code set used for reporting services and supplies, with Level I consisting of CPT codes and Level II covering products, supplies, and services not described by CPT.

The diagnosis code set used in the United States to document patient conditions and justify the medical services reported on a claim.

A category of CPT codes that reports the level of work involved in patient encounters such as office visits, based on factors like history, examination, and medical decision making.

The process of recording the services, supplies, and procedures delivered to a patient so they can be translated into billable charges on a claim.

A facility's internal list of services and supplies with their assigned prices and codes, which is maintained as the source for generating patient charges.

A claim that contains all required data elements, passes edits for accuracy and completeness, and can be adjudicated by the payer without additional information or correction.

An intermediary that receives electronic claims from providers, checks them against formatting and payer edits, and routes accepted claims to the correct insurance payer.

The computer-to-computer exchange of standardized business documents, such as claims and remittance advice, between healthcare organizations using HIPAA transaction formats.

Software that reviews claims before submission for missing data, coding conflicts, and payer-specific rules so errors are corrected prior to transmission.

An electronic version of a payer's payment explanation that reports claim decisions, paid amounts, and adjustments in a standardized format for posting to the billing system.

A statement from the payer to the patient or provider summarizing how a claim was processed, including allowed charges, payments, patient responsibility, and denial reasons.

The maximum amount a payer will recognize for a covered service under its contract, which serves as the basis for calculating payment and patient cost sharing.

A payer's published list of payment rates for specific services and codes, which determines the allowed amount for contracted providers.

A reimbursement method that pays a predetermined fixed amount for a defined episode or service category, such as a hospital stay, rather than paying separately for each item used.

A classification system that groups inpatient hospital stays into categories based on diagnosis and procedures, used to set a fixed payment for the admission.

A payer's refusal to pay all or part of a claim, often because of missing information, lack of medical necessity, eligibility problems, or coding errors.

A formal request by a provider or patient asking a payer to reconsider a denied or underpaid claim, supported by clinical documentation and the reason for the dispute.

The deadline set by a payer or contract by which a claim or appeal must be submitted to be considered for payment, after which it may be denied outright.

The total money owed to a provider for services already delivered but not yet paid, tracked by aging categories to monitor collection performance.

A report that groups outstanding balances by how long they have been unpaid, such as 0-30, 31-60, and 61-90 days, to highlight collection risk.

A performance measure showing the average number of days it takes to collect payment on outstanding balances, calculated by dividing total A/R by average daily charges.

The percentage of submitted claims accepted by payers on first pass without rejection or correction, used as an indicator of front-end billing accuracy.

The percentage of claims or charges denied by payers in a period, used to measure billing accuracy and identify recurring process problems.

A federal law that imposes liability on individuals and organizations that knowingly submit false or fraudulent claims for payment to government healthcare programs.

A federal law that prohibits offering, paying, soliciting, or receiving anything of value to induce referrals or generate business for items or services paid by federal healthcare programs.

A federal law that prohibits physicians from referring patients for certain designated health services to entities in which the physician or an immediate family member has a financial relationship, unless an exception applies.

A legal action brought by a private person on behalf of the government alleging fraud, with the relator potentially receiving a share of any recovered funds.

Reporting a service with a higher-paying code than the documentation supports, which is a form of fraudulent billing when done intentionally.