CBCS flashcards

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

Prior authorization

Payer approval obtained before a service is rendered. Missing authorization often causes denial, so the auth number, approved units, CPT codes, and valid date range must be documented.

Eligibility verification

Confirms active coverage, effective dates, plan type, and patient cost-sharing before services are performed. It is often completed electronically through a 270/271 transaction.

Coordination of benefits

Rules that determine which payer is primary and which is secondary when a patient has multiple coverages. The birthday rule commonly applies to dependent children.

Referral vs prior auth

A referral is provider-to-provider permission often required by HMO plans for specialist visits. Prior authorization is payer approval; both may be required for one service.

270/271 transaction

HIPAA X12 electronic eligibility inquiry (270) and response (271) exchanged between provider and payer to verify coverage in real time.

Insurance card data

Member ID, group number, plan effective date, primary care provider, copays, and payer contact information are key elements used during eligibility verification.

Medicare Advantage prior auth

Many Medicare Advantage plans require authorization for services that Original Medicare may not. Plan-specific rules must be verified before scheduling or rendering.

ICD-10-CM

Diagnosis coding system used on healthcare claims. Codes are three to seven characters, begin with a letter, and include laterality and seventh-character encounter details.

CPT Category I

Five-digit codes describing established medical procedures and services. Category II codes are performance measures, and Category III codes cover emerging technology.

HCPCS Level II

Alphanumeric codes beginning with a letter that cover drugs, supplies, durable medical equipment, and services not represented in CPT.

Modifier 25

Appended to an evaluation and management code to show a significant, separately identifiable E/M service was performed on the same day as a procedure.

Modifier 59

Identifies a distinct procedural service and may override National Correct Coding Initiative bundling when the services are truly separate and not bundled.

Medical necessity

The link between a performed procedure and a supporting diagnosis. The first-listed ICD-10-CM code should reflect the reason the service was provided.

E/M MDM or time

Office evaluation and management level is selected using medical decision making or total time on the date of service; history and exam no longer determine level.

CMS-1500

Paper claim form used for professional services. Institutional or facility claims use the UB-04 form instead.

837P claim

HIPAA X12 electronic transaction used to submit professional claims. The 837I transaction is used for institutional claims.

Clean claim

A claim with complete and accurate data that passes payer edits and requires no additional information before adjudication.

NPI

Ten-digit National Provider Identifier. Type 1 identifies individual providers, and Type 2 identifies organizations such as hospitals or group practices.

EOB vs ERA

An EOB is a paper explanation of benefits. An ERA, or 835 transaction, is the electronic remittance advice used for automated payment posting.

Denial vs rejection

A rejection is not accepted for processing because of format or data errors. A denial is processed and then denied for coverage, eligibility, or medical necessity reasons.

A/R days

Calculated as total accounts receivable divided by total charges, multiplied by days in the period. It measures how long receivables take to collect.

Aging buckets

Categories such as 0-30, 31-60, 61-90, and 120-plus days used to monitor overdue receivables and prioritize follow-up.

First-pass resolution rate

Percentage of claims paid on first submission without denial or rework. It is a key revenue cycle key performance indicator.

Charge capture

Process of recording all services and supplies delivered so they appear on claims. Missed charges directly reduce practice revenue.

Contractual adjustment

Difference between billed charges and the payer-allowed amount. It is written off according to the payer contract and is not patient responsibility.

Credit balance

An overpayment on a patient account that must be refunded or offset within payer-specified timeframes to avoid compliance issues.

HIPAA Privacy Rule

Governs use and disclosure of protected health information. It permits treatment, payment, and healthcare operations without patient authorization.

HIPAA Security Rule

Requires administrative, physical, and technical safeguards to protect electronic protected health information from unauthorized access, alteration, or destruction.

Minimum necessary

HIPAA principle requiring that only the least amount of protected health information needed for a purpose be used or disclosed.

Breach notification

Covered entities must notify affected individuals within 60 days of discovering a breach; breaches affecting more than 500 people also require HHS and media notice.

Anti-Kickback Statute

Federal law prohibiting offering or receiving remuneration to induce referrals for healthcare services paid by federal programs such as Medicare or Medicaid.

Stark Law

Prohibits physician self-referral for designated health services reimbursed by Medicare when the physician has a financial relationship with the entity.