Explanation of Benefits and Payment Adjudication

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Across
  1. 1. Claims with errors or simple mistakes are rejected, and the payer transmits instructions to the provider to correct errors and/or omissions and to __________ the service. Answer: Rebill
  2. 3. Providers use different methods to determine their fee structure, including charged-based and __________ fee structures. Answer: Resource-Based
  3. 7. A provider can decide if their usual fees should be at the high, low, or __________ range based on fee comparisons. Answer: Midpoint
  4. 8. The medical office specialist is responsible for completing many steps, including obtaining a correct and complete __________ information form. Answer: Patient
  5. 9. A claim examiner will check that the diagnosis and CPI codes are linked when reviewing claims. The diagnosis and procedures are reviewed to be sure the treatment was medically __________. Answer: Necessary
  6. 13. The medical office specialist who is posting payments needs to be aware of __________ by the payer and take appropriate action. Answer: Downcoding
  7. 14. Accounts receivables represent monies owed to a provider by insurance carriers or the patient/insured. These payments are applied to the patient's account to reduce the overall __________ due. Answer: Balance
Down
  1. 1. The act of submitting a claim again after it has been denied is called __________. Answer: Resubmitting
  2. 2. Rejected or delayed insurance claims are expensive for the medical facility because resubmitting a claim means that work is __________. Answer: Repeated
  3. 3. The RBRVS system is composed of three elements measured in __________. Answer: RVUs
  4. 4. The process of determining whether a procedure is medically necessary is called __________. Answer: Review
  5. 5. The adjustment reason codes on an EOB/ERA inform the medical office specialist about the reason for the denial, the amount due from the patient, incorrect coding, and so on. Answer: Denial
  6. 6. The insurance carrier's decision regarding whether or not to pay a claim is called __________. Answer: Adjudication
  7. 10. An EOB informs the medical office specialist about the reason for the denial, known as an __________ reason code. Answer: Adjustment
  8. 11. An Explanation of Benefits (EOB) is a notification form sent from the insurance carrier to the patient and the healthcare provider after an insurance claim has been __________. Answer: Processed
  9. 12. The act of processing a claim that consists of edits, review, and determination. Answer: Adjudication