QBRS flashcards

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

Net collection rate

Payments received divided by allowed amount after contractual adjustments. It measures how much of collectible revenue the organization actually captured.

Days in accounts receivable

Total accounts receivable divided by average daily net charges for the period. It estimates how many days of revenue remain uncollected.

Clean claim rate

The percentage of claims accepted on first submission without edits, rejections, or denials. It is a key front-end revenue cycle indicator.

Cost to collect

Total revenue cycle operating expense divided by total cash collected. It expresses the efficiency of the billing operation as a percentage.

Coordination of benefits

The process that determines which payer is primary and which is secondary when a patient has multiple coverages, preventing duplicate payment.

Birthday rule

For dependent children covered by both parents, the plan of the parent whose birthday falls earlier in the calendar year is primary.

Real-time eligibility check

An electronic 270/271 transaction sent to a payer that returns active coverage, benefit levels, and patient cost-sharing before the visit.

Guarantor

The person legally responsible for paying a patient account, who may or may not be the patient receiving the services.

Medicare Secondary Payer

Rules that make Medicare the secondary payer when another plan, such as an employer group health plan based on current employment, pays first.

Modifier 25

A modifier appended to an evaluation and management code to indicate a significant, separately identifiable service on the same day as a procedure.

National Correct Coding Initiative

Edit pairs published by CMS identifying code combinations that are not separately payable, some of which may be overridden with a modifier.

Medical necessity

The requirement that a service be reasonable and necessary for the diagnosis or treatment of a condition, supported by clinical documentation.

Charge capture

The process of recording all services, supplies, and procedures delivered so they can be coded and billed accurately.

UB-04 claim form

The institutional paper claim form, also known as the CMS-1450, used to bill facility services to Medicare and other payers.

CMS-1500 claim form

The standard paper claim form used to bill professional services, such as physician and non-institutional provider services.

837P transaction

The ANSI ASC X12N electronic standard used to submit professional claims to payers through a clearinghouse.

Claim rejection

A claim returned before payer adjudication because of a data or format error; it can be corrected and resubmitted.

Timely filing limit

The maximum period after the date of service or claim submission within which a payer will accept a claim for adjudication.

Electronic remittance advice

The 835 transaction that delivers payment, adjustment, and denial information from the payer to support automated posting and reconciliation.

Denial rate

The number of denied claims divided by total claims submitted for the period, often tracked alongside denied dollar value.

Root cause analysis

A structured review that assigns each denial to a front-end, mid-cycle, or back-end owner so the underlying process can be corrected.

First-level appeal

The initial formal reconsideration request submitted to a payer after a denial, supported by documentation and a rationale letter.

Preventable denial

A denial caused by an internal error such as registration, authorization, or coding, which could have been avoided before submission.

A/R aging

The classification of outstanding account balances by the number of days since service or billing, typically in 30-day increments.

Patient responsibility

The portion of an allowed charge the patient owes, including copay, coinsurance, deductible, and non-covered services.

Point-of-service collection

Collecting patient cost-sharing at the time of service, before or during the visit, rather than after claim adjudication.

Financial assistance policy

An organization's written criteria for discounting or writing off charges for eligible low-income patients, applied consistently and documented.

Anti-Kickback Statute

A federal law prohibiting remuneration intended to induce referrals for items or services payable by federal health care programs.

Stark Law

A law prohibiting physician self-referral for designated health services when a financial relationship exists, unless a specific exception applies.

60-day repayment rule

Requires reporting and returning identified Medicare overpayments within 60 days of identification to avoid False Claims Act liability.

OIG exclusion list

The List of Excluded Individuals and Entities; billing federal programs for services provided by an excluded person can create liability.

Good-faith estimate

A price transparency disclosure of expected charges for a scheduled service, provided to uninsured or self-pay patients upon request.