AMT CMAS key terms

A fixed dollar amount a patient pays at the time of service, such as $25 for an office visit, with the insurance plan covering the remainder of the allowed charge.

The percentage of allowed charges a patient pays after meeting the deductible, for example 20 percent, while the plan pays the other share.

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share of the cost.

The maximum dollar figure a payer will recognize as payment for a given service under its contract, which serves as the basis for calculating plan and patient responsibility.

A statement from the insurer showing services billed, the allowed amount, what the plan paid, and what the patient owes, but which is not itself a bill.

An electronic or paper report sent to the provider with payment, listing each claim, the amount paid, and any adjustment or denial reason codes.

A claim submitted with all required data elements complete and accurate, allowing the payer to process it without requesting additional information or correction.

A payer's refusal to pay all or part of a submitted claim, often due to missing information, ineligibility, coding problems, or lack of medical necessity.

A formal request asking a payer to reconsider a denied or underpaid claim, usually supported by documentation and submitted within a stated deadline.

The standard that a service must be reasonable and required for the diagnosis or treatment of a patient's condition to be covered by a payer.

Approval a payer requires before certain services, procedures, or medications are delivered, confirming the plan will cover them if criteria are met.

A provider's written or electronic direction sending a patient to another provider, often required by managed care plans before specialty care is covered.

A clinician or facility that has signed a contract with an insurance plan to accept its negotiated rates and follow its rules in exchange for network access.

The process that determines which of a patient's multiple insurance plans pays first and how the secondary plan covers remaining balances.

The health plan that pays a claim first when a patient has more than one source of coverage, before any other plan is billed.

A health plan that considers a claim only after the primary plan has paid, covering some or all of the remaining patient responsibility.

The difference between a provider's billed charge and the amount the payer contract allows, which the provider writes off and cannot bill to the patient.

An amount a practice removes from a patient's account balance because it will not be collected, such as a contractual adjustment or an approved financial hardship.

The total money owed to a medical practice for services already provided, tracked by age to monitor how quickly claims and patient balances are paid.

A report that groups unpaid claims and patient balances by how many days they have been outstanding, helping staff prioritize collection follow-up.

A standardized code set maintained by the American Medical Association that describes medical services and procedures for billing and reporting purposes.

The code set used in the United States to report diagnoses and reasons for visits on claims, organized by body system and condition.

A national code set used mainly for supplies, drugs, durable medical equipment, and services not described by CPT codes.

A CPT code category used to bill office visits and other encounters, selected by documented elements such as history, examination, and medical decision making.

The complexity of thinking a provider documents about a patient's problems, data reviewed, and risk, used to select some E/M visit levels.

Billing a service at a higher level or cost than the documentation supports, which is a form of fraud and can lead to payer audits and penalties.

Intentional deception for financial gain in health care, such as billing for services never rendered or knowingly submitting false information to a payer.

Practices that are inconsistent with accepted business or medical standards and cause unnecessary cost, even without proof of intentional deception.

A federal law that imposes penalties on persons or entities who knowingly submit false or fraudulent claims to government health programs.

A federal law that protects the privacy and security of individually identifiable health information and sets rules for its permitted use and disclosure.

Health information that identifies a patient and relates to care, payment, or health status, and which is safeguarded by federal privacy rules.

The principle that only the least amount of protected health information needed for a task should be accessed, used, or shared.

A signed patient authorization permitting a practice to disclose specified health information to a named person or organization for a stated purpose.

A patient's voluntary agreement to a procedure or treatment after receiving an explanation of its risks, benefits, and alternatives.

A legal document in which a patient states wishes about future medical care or names someone to decide, used when the patient cannot speak for themselves.

A common progress-note format that records the patient's reported symptoms, exam findings, the provider's assessment, and the treatment plan.

The main reason a patient seeks care, usually stated briefly in the patient's own words at the start of the encounter.

A narrative description of the current problem, including onset, location, duration, character, aggravating factors, and related symptoms.

A series of questions reviewing symptoms by body system to identify problems the patient may not have mentioned spontaneously.

A dated entry in the medical record describing a patient's status, care given, and plan during a specific visit or encounter.

The complete legal collection of a patient's health information, including notes, test results, and correspondence, kept confidential and retained per policy.

A document or electronic screen used during a visit to capture the diagnoses, services, and supplies delivered so they can be coded and billed.

A routing form listing common diagnoses and services for a specialty, checked by the provider to communicate what should be billed for the visit.

The process of recording every service and supply provided to a patient so that nothing billable is missed or incorrectly reported.

A preset pattern of appointment slots that controls visit length and availability for a provider's day.

The intake step in which demographic, insurance, and consent information is collected and entered to establish or update a patient's record.

The process of confirming with a payer that a patient's coverage is active and what benefits apply before services are rendered.

A communication technique in which the listener focuses fully, reflects back what was heard, and asks clarifying questions to confirm understanding.

Purposeful verbal and nonverbal interaction that supports a patient's comfort and understanding, using open questions, empathy, and respect.

A technique where the patient explains instructions in their own words so staff can confirm understanding and correct misunderstandings.

A person's ability to obtain, understand, and use health information to make appropriate decisions about their care.

A trained professional who conveys spoken communication accurately between a patient with limited English proficiency and the care team.

The tasks and duties a health worker is legally permitted to perform based on licensure, certification, and state law.

The level of care and skill that a reasonably competent professional in the same field would provide under similar circumstances.

A failure to exercise the degree of care a reasonable professional would use, resulting in harm to a patient.

Professional negligence by a health care provider that causes injury, typically addressed through civil legal action.

The limits that keep the medical relationship focused on the patient's needs, avoiding personal, financial, or romantic entanglements.

The ethical and legal duty to keep patient information private and share it only with those authorized to receive it.

A credential earned by passing a recognized exam and meeting education or experience requirements, demonstrating entry-level competence in the field.

Ongoing training units that credentialed professionals complete to maintain certification and stay current with changes in practice.