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NHA CBCS Study Guide! questions and answers rated A+ 2024/2025
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NHA CBCS Study Guide!Adjudication
The system wherein the insurance employer gets a claim and makes a determination on
price or denial.
Allowed Amount
The most amount an insurance employer will pay for the service, procedure, or supply.
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Auditing Process
The act of reviewing and evaluating the patient scientific facts and claims to evaluate for
coding appropriateness and completeness of the medical documentation.
Coding Compliance
The conformity and adherence to set up coding pointers and rules.
Current Procedural Terminology (CPT)
Descriptive definitions used to give an explanation for strategies and offerings furnished to
the patient.
Denied Claim
A declare lower back from a third-celebration payer because of technical mistakes or
affected person coverage errors.
Explanation of Benefits (EOB)
,Document that explains how the payer processed the claim for offerings rendered; can also
be referred to as remittance recommendation (RA).
Fee-for-Service
Cost or rate that is charged for each man or woman service.
Health and Human Services
Government department that oversees the health of the community and presents vital
services.
International Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM)
List of codes used to record and classify diseases, conditions and other reasons for fitness
care encounters.
Noncompliance
The act of dismissing guidelines and tips outlined by using state and federal authorities
companies and 0.33-celebration payers.
Office of Inspector General (OIG)
Government branch that investigates fraud and abuse.
Place of Service (POS) Code
Two-digit code that identifies wherein the offerings had been finished.
Abuse
Billing styles and practices that are immoderate or pointless however now not fraudulent. -
When the issuer unknowingly or unintentionally misrepresented records on a claim for
compensation.
Accounts Receivable
The amount owed to a company for health care offerings rendered.
Appeals Process
A manner used to request review of a claim that turned into denied---to determine if the
denial was because of a billing mistakes; if so, correct it; record an appeal at the bottom
stage; after which pass up to better tiers if needed.
Assignment of Benefits
,Method of a patient requesting their declare benefits be paid to the health care organisation
that furnished the carrier.
Beneficiary
Person eligible to get hold of blessings for protected fitness care offerings rendered.
Coinsurance
Predetermined percent the affected person is responsible to pay for included offerings as
soon as the yearly deductible has been met.
Copayment (copay)
Flat, fixed amount that a patient can pay for precise services (e.G., workplace or Emergency
Department encounters). // Many policies have a $25 copay for PCP office visits and
$35-$50 copay for specialists)
Covered Entity
Entity that transmits health facts in digital form (e.G., vendors, fitness plans, clearinghouses)
Deductible
The annual quantity the affected person have to pay before the coverage will begin to pay
for blanketed benefits.
Electronic Data Interchange (EDI)
Computer technology that contains the trade of data among the fitness care provider and
payer.
Eligibility
Process of verifying the affected person has coverage insurance and has benefits for the
services to be furnished.
Encounter shape
Document that captures diagnoses or process codes for the services furnished at some
point of the affected person's encounter (electronic or paper format).
Fraud
Intentionally billing for offerings no longer completed, reporting fraudulent diagnoses, or
clinical coding mistakes. - Intentionally looking ahead to a fee on a claim while the company
is aware about wrongdoing, billing for services that had been not provided.
, Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Federal act that governs and mandates rules that consist of privacy, confidentiality, and
safety for health care data and facts.
Medical Necessity
Process of presenting analysis codes that aid the services rendered to the affected person;
coding for medical necessity includes associating relevant prognosis codes (ICD-10-CM) to
provider/system codes (CPT) inside the billing software program, that's called linking/linkage.
Out-of-Pocket
Patient responsibility part of a medical health insurance plan defined by using the payer
(includes annual deductible, copay, and coinsurance amounts).
Preauthorization
The acclaim for a carrier or system, and well timed filing is the time-frame to submit a
declare.
Precertification
Process of figuring out a patient's coverage details for fitness care offerings (e.G., laboratory
or imaging offerings, hospitalizations, surgical strategies).
Protected Health Information (PHI)
Individually identifiable patient facts.
Revenue Cycle Management (RCM)
Process that health care vendors use to control financial viability by growing revenue,
enhancing coins drift, from registration to very last payment.
Third-Party Payer
Health care insurance corporation that reimburses offerings supplied by means of vendors
and/or health care organizations.
Utilization Management
Method used to govern health care cost, through reviewing the appropriateness and medical
necessity of offerings rendered to the sufferers previous to the remedy being done.
HMO
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