CHAA key terms

The front-end hospital function that schedules, registers, verifies coverage, and collects patient payments before and at the time of service, setting the accuracy and financial foundation for the rest of the revenue cycle.

The process of collecting patient demographic, insurance, and clinical information by phone or online before the visit, so the encounter can be completed faster and eligibility checked in advance.

Confirming with the payer, through a portal, phone call, or electronic transaction, that a patient's coverage is active on the date of service and what benefits the plan includes.

A payer's advance approval that a specific service, drug, or procedure is medically necessary and will be covered; without it, the claim may be denied and the patient billed.

Completing all financial steps before service, including eligibility, benefits, authorization, and cost estimation, so the organization knows what will be paid and what the patient owes, reducing later denials and bad debt.

Asking patients to pay estimated copayments, deductibles, or deposits at check-in, discharge, or another point during the visit rather than waiting for a mailed statement.

The rules payers use to decide which plan pays first when a patient has more than one health plan, preventing duplicate payment and assigning any remaining balance correctly.

A calculation given to the patient before or at service that projects their out-of-pocket cost, such as copay, deductible, and coinsurance, based on verified benefits and expected charges.

All administrative and clinical steps that generate and collect payment for care, beginning with scheduling and registration and ending with claim adjudication, payment posting, and denial follow-up.

A claim submitted with every required data element accurate and complete, so the payer can process it without requesting more information or returning it as unprocessable.

The maximum amount a payer will recognize for a covered service under its contract or fee schedule; for in-network care the provider usually writes off charges above this figure.

The difference between a provider's billed charge and the amount the payer's contract allows; it is written off and cannot be billed to the patient.

A statement from the insurer telling the patient which services were processed, what the plan paid, what was adjusted, and what the patient owes.

A payer's report to the provider explaining how each claim was adjudicated, including paid, denied, and adjusted amounts; the electronic version is the 835 transaction.

The systematic review, correction, appeal, and prevention of claims a payer did not pay, aimed at recovering revenue and stopping the same error from recurring.

A provider's internal master list of prices for every service, supply, and room charge, used to generate the billed charges that payers then adjust to contracted rates.

Individually identifiable health information held or transmitted by a covered entity or business associate, in any form, that relates to a person's past, present, or future care or payment.

Federal regulation setting national standards for how covered entities may use and disclose protected health information and what rights patients have over their own records.

The requirement that covered entities limit each use or disclosure of protected health information to the least amount reasonably needed to accomplish the purpose, with exceptions such as disclosures for treatment.

A written statement a covered entity must give patients describing how their health information may be used and disclosed and how they can exercise their privacy rights.

The three routine purposes for which a covered entity may use or disclose protected health information without patient authorization, such as coordinating care, billing, and quality review.

A signed, specific, and revocable permission from the patient allowing a covered entity to use or disclose health information for purposes that go beyond treatment, payment, or operations.

A federal law requiring Medicare-participating hospitals with emergency departments to perform a medical screening exam and provide stabilizing treatment regardless of the patient's insurance or ability to pay.

A written notice a provider gives a Medicare beneficiary before a service that may not be covered, so the patient can decide whether to receive it and accept financial responsibility.

A HIPAA rule requiring covered entities to notify affected individuals, and the Department of Health and Human Services, when unsecured protected health information is improperly accessed or disclosed.

A communication technique of giving full attention, avoiding interruption, and reflecting or summarizing what the speaker said to confirm the message was understood correctly.

The practice of recognizing and naming a patient's feelings and perspective, then communicating that understanding, which lowers tension and builds trust during stressful encounters.

The steps a staff member takes when a patient is upset or a service has failed, such as listening, apologizing, fixing the problem, and following up, to rebuild trust and keep complaints from escalating.

A person's ability to find, understand, and use basic health information and services to make informed decisions; limited health literacy calls for plain language and extra confirmation of understanding.

A check for understanding in which the patient explains instructions in their own words or demonstrates a task, letting staff correct misunderstandings before the patient leaves.

Qualified interpreters and translated written materials provided so patients with limited English proficiency or hearing loss can understand and take part in their care, as federal rules often require.

A digital, shareable record of a patient's health information, including history, orders, results, and notes, used by clinicians to document and coordinate care across encounters.

A database that assigns one unique identifier to each patient and links all of that patient's records, helping staff find the right chart and prevent duplicate or overlapping medical records.

The computer-to-computer exchange of standardized healthcare transactions, such as 837 claims, 835 remittances, and 270/271 eligibility inquiries, between providers and payers.

An intermediary that receives electronic claims from providers, checks them for errors and formatting problems, then routes them to the correct payer and returns the payer's response.

The electronic sharing of patient health information among separate organizations, such as hospitals, physician practices, and laboratories, so clinicians have complete data at the point of care.

An electronic inquiry (270) sent to a payer that immediately returns a response (271) confirming whether coverage is active and which benefits apply on the date of service.