NHA CMAA key terms

A fixed dollar amount a patient pays at the time of a covered service, such as a $25 office visit fee. The insurance plan pays the remainder of the allowed charge.

The patient's share of a covered service's cost, expressed as a percentage after the deductible is met. For example, 20% coinsurance means the plan pays 80% of the allowed amount.

A set amount a patient must pay out of pocket for covered services each plan year before the insurance plan begins paying its share of the cost.

A statement from the insurer showing services billed, the allowed amount, what the plan paid, and any patient responsibility. It is not a bill.

The maximum charge a payer will recognize for a specific service under its contract with the provider. Patient cost sharing and plan payment are calculated from this figure.

The standard paper claim form used to bill Medicare, Medicaid, and most commercial insurers for outpatient professional services. It captures patient, insured, provider, diagnosis, and procedure information.

The total money owed to the practice for services already delivered. Staff monitor this balance to ensure claims and patient balances are collected promptly.

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

A form or screen used during a visit to record the diagnoses, procedures, and charges delivered. It becomes the source document for creating the insurance claim.

A payment model in which a provider receives a fixed amount per patient per month, regardless of how many services that patient uses.

A reduction to a patient's account balance that is not expected to be collected, such as a contractual discount or an approved charity care amount.

A document from a payer that lists claims processed and shows payment, denial, or adjustment for each. Electronic versions are used to post payments automatically.

The intake process that collects and verifies a patient's demographic, insurance, and contact information and creates or updates the patient record before services.

A recurring layout in the scheduling system that blocks time for appointments, procedures, meetings, and administrative work so available visit slots match provider preferences.

A tracking method that identifies patients due for services such as annual exams, immunizations, or follow-up visits and prompts staff to contact them.

Written rules describing what happens when a patient misses an appointment without notice, including fees, documentation, and conditions for future scheduling.

Approval a payer requires before certain services, drugs, or referrals are covered. Staff submit clinical details and wait for a decision before scheduling.

A request from one provider asking another to evaluate or treat a patient for a specific problem, often requiring documentation and payer approval.

The system used to schedule appointments, register patients, enter charges, submit claims, post payments, and generate reports on practice finances.

A reminder system organized by date that holds items needing future action, such as pending authorizations, unpaid claims, or follow-up calls.

A communication technique in which the listener gives full attention, avoids interrupting, and confirms understanding by summarizing or asking clarifying questions.

The ability to recognize and acknowledge another person's feelings and perspective, then respond in a way that shows understanding without taking on the emotion.

Purposeful, patient-centered conversation that supports assessment, education, and emotional comfort while keeping focus on the patient's needs rather than staff concerns.

A patient's ability to obtain, understand, and use health information to make decisions. Staff adjust teaching, wording, and materials to match that ability.

The ongoing ability to recognize and respect differences in language, values, religion, and health beliefs, and to adapt communication and care accordingly.

Techniques used to calm an upset or angry person, such as speaking softly, giving space, listening without arguing, and offering choices that restore control.

Limits that keep the medical assistant's relationship with patients focused and appropriate, avoiding personal favors, social contact, or sharing of private staff information.

A structured approach to disagreement that identifies the problem, allows each side to be heard, and seeks a workable solution while preserving respectful working relationships.

A trained individual who conveys spoken messages accurately between a patient with limited English proficiency and the care team, without adding advice or opinions.

Individually identifiable health information created or held by a covered entity, in any form, that relates to a person's physical or mental health, care, or payment.

A written statement explaining how a practice may use and disclose health information, the patient's rights, and how to file a complaint. Patients receive it at first service.

The requirement to limit access to and disclosure of health information to the least amount needed to accomplish the intended purpose.

A signed permission form that names the information to be disclosed, the recipient, the purpose, and an expiration date, and states the patient's right to revoke.

A record the practice keeps of certain disclosures of health information outside treatment, payment, and operations, which patients may request for up to six years.

A patient's ability to ask that incorrect or incomplete information in the medical record be changed, with the practice responding in writing to accept or deny.

The required process of informing affected individuals, and sometimes regulators, when unsecured health information is accessed or disclosed without authorization.

The schedule that sets how long records must be kept before destruction, based on state law, payer contracts, and the age of the patient at last visit.

An automatic log that records who accessed or changed an electronic record, when, and from which device, allowing review of possible misuse.

A legal order requiring a practice to produce specified records or appear with them. Staff verify validity and follow release rules before responding.