#1
What is a healthcare claim?
A request for payment sent by a healthcare provider to the insurance company
ExplanationRequest for payment by healthcare providers to insurers
#2
What is adjudication in healthcare claims processing?
The process of determining the validity of a healthcare claim and calculating the amount owed
ExplanationValidity determination and payment calculation in claims processing
#3
What is a common reason for a healthcare claim to be denied?
Incomplete or inaccurate information on the claim form
ExplanationDenial due to incomplete or inaccurate claim information
#4
What is a deductible in health insurance?
The amount an insured individual must pay out-of-pocket for covered services before the insurance company begins to pay
ExplanationOut-of-pocket payment by insured before insurance coverage kicks in
#5
What is a healthcare claim scrubber?
A software tool that checks healthcare claims for errors and inconsistencies before submission
ExplanationSoftware tool for error-checking in healthcare claims
#6
What is the purpose of the ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes in healthcare claims?
To classify diseases and health problems recorded on healthcare claims
ExplanationClassifying diseases and health problems in claims
#7
What is an Explanation of Benefits (EOB) statement?
A document sent by the insurance company explaining how a claim was processed and what portion the patient is responsible for paying
ExplanationInsurance document explaining claim processing and patient responsibility
#8
What is a Coordination of Benefits (COB) in healthcare claims processing?
A process for coordinating insurance coverage when a patient is covered by more than one insurance plan
ExplanationCoordinating coverage for patients with multiple insurance plans
#9
What is a pre-authorization requirement in healthcare claims processing?
A requirement for healthcare providers to obtain approval from the insurance company before providing certain treatments or services
ExplanationApproval requirement before providing specific treatments or services
#10
What is a common reason for a healthcare claim to be pended?
The need for additional information or review before the claim can be processed
ExplanationPending due to additional information or review requirement
#11
What is a COBRA continuation coverage?
A federal law that allows employees to continue their group health insurance coverage after leaving their job
ExplanationFederal law for continuing group health insurance coverage after job termination
#12
What is the role of a claims examiner in healthcare claims processing?
To review healthcare claims for accuracy and compliance with insurance policies
ExplanationReviewing claims for accuracy and policy compliance
#13
What is the role of a healthcare claims adjuster?
To evaluate insurance claims and negotiate settlements
ExplanationEvaluating claims and negotiating settlements