Intro to Claims Terminology

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Across
  1. 6. Amount insurance company agreed to pay for procedure or service
  2. 8. Codes used to document dental treatment
  3. 12. Amount a patient owes a provider after the insurance company has paid their portion of a claim
  4. 15. Date the claim or pre-authorization is settled by claims
  5. 16. Process for recovering overpayment to a patient or provider
  6. 17. International Classification of Diseases and Used to identify reason for patient-physician encounter
  7. 20. Form providing common format for reporting dental services to a patient’s plan
  8. 22. Internal clearing house used by Avēsis
  9. 23. Payment statement sent to provider after a claim is processed (aka Remittance Advice)
  10. 24. Form used to submit claims for vision services to a patient’s plan
  11. 25. Code indicates claim received through clearing house
  12. 26. Replacement of a previously submitted claim to fix incorrect or missing information
  13. 27. Any specific situation, condition, or treatment that a health insurance plan does not cover
Down
  1. 1. Period of time a patient needs to wait before they become eligible for coverage or a specific service under a plan
  2. 2. Two-digit codes that provide additional information about a billed procedure
  3. 3. Codes used to explain reasons why a claim was paid or denied
  4. 4. Comprehensive listing of fee maximums used to reimburse providers on a fee-for-service basis
  5. 5. Process of evaluating a claim for payment of benefits
  6. 7. Any claim submitted by a provider for the same service provided to a patient on a specified date that was included in a previously submitted claim
  7. 9. Benefits statement sent to member and provider after a claim is processed
  8. 10. Codes used to document medical procedures
  9. 11. Form providing common format for reporting vision or hearing services to a patient’s plan
  10. 13. Allows Providers to submit electronic attachments with claims
  11. 14. Person who decides whether a patient’s insurance policy covers a medical procedure
  12. 16. Coverage options that enable a patient to expand basic insurance plan for an additional premium
  13. 18. Company providing electronic submission and translation services between providers and insurance companies
  14. 19. Process of creating a new claim from one previously submitted to record as a duplicate or correct information
  15. 21. Electronic claim form