SHC 101-102 TERMINOLOGY

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Across
  1. 5. Medical code ranging from three to five digits that explains the medical condition of the patient
  2. 7. This is the standard claim form used for Hospital and other facilities
  3. 12. A system used to classify inpatient hospital stays into cost, utilization and complexity groups for the purposes of standardizing payments across the country
  4. 16. The major state based government insurance program for low income and disabled Americans
  5. 18. The process by which procedures and diagnoses are translated into a standardized set of numerical values to assist in the completion of the final bill
  6. 19. abbr a provision in a contract that applies when a person is covered under more than one group medical program it requires that payment of benefits be coordinated by all programs
  7. 20. The main purpose is to resubmit a claim when the payer indicates they have not received it - should not be used as a method to follow up on the status of a claim that has already been billed
  8. 21. Class of DRGs that were developed to reflect the clinical complexity of the overall patient population
  9. 22. Health insurance plans that limit the access and utilization of their subscriber's services to a defined or managed list of providers
  10. 23. Payment system where health care provider receives negotiated per member per month PMPM fee to provide care for enrollees-provider bears risk for costs above PMPM and reaps rewards for costs lower than PMPM
  11. 24. Front end revenue cycle is more formally called _____ which describes the processes before a patient receives services
  12. 25. The role of the primary point of contact and representative of the organization to patients and guarantors who have issues with their bills
  13. 26. What does SHC call money in the patient bucket
  14. 27. The amount of money the patient is responsible for before the healthcare coverage begins to pay for eligible benefits
Down
  1. 1. Electronic file sent by an insurer that includes payment and denial information for patient accounts
  2. 2. The major government health insurance program for Americans 65 and older and nonelderly people with disabilities
  3. 3. The Medicare Rule that states that if a patient receives outpatient services three days before a hospital admission, then the facility cannot bill MCR separately for the outpatient services as they are considered incidental to the inpatient services
  4. 4. A percentage discount to the billed charges presented on a claim
  5. 6. abbr Healthcare Common Procedure Coding System
  6. 8. Hospital and Payors use clinical decision support criteria to determine the appropriateness of care resource usage
  7. 9. abbr A system used to classify inpatient hospital stays into cost, utilization and complexity groups for the purposes of standardizing payments across the country
  8. 10. abbr a type of managed care organization whose providers have agreed with a payer or third party administrator to provide health care at reduced rates to the insurer's or administrator's clients
  9. 11. abbr Current Procedural Terminology codes-first level of the HCPCS coding system - five digit codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals
  10. 13. abbr a written notice given by a provider to a MCR beneficiary advising him/her in advance that Medicare may not pay for a service and that he/she will be responsible for payment
  11. 14. An error free claim that is submitted to a payer for payment
  12. 15. The portion of cost the patient is responsible for and often applies after meeting the deductible requirements of their contract
  13. 17. is comprised of clinical documentation charge entry and charge reconciliation
  14. 25. abbr Office containing consolidated revenue cycle functions