PAR Medical Terminology and Clinical Documentation Flashcards

What does 'EOB' stand for, and who typically receives it?

Answer: Explanation of Benefits; sent to the patient and/or provider after a claim is processed

An EOB (Explanation of Benefits) is a statement from the insurer detailing how a claim was processed, including amounts billed, allowed, paid, and the patient's responsibility.

What defines a 'clean claim' in medical billing?

Answer: A claim submitted with all required data elements completed accurately and no missing or invalid information

A clean claim contains all required data elements, has no errors or missing information, and can be processed for payment without additional information from the provider.

What does 'COB' stand for in insurance, and why is it important?

Answer: Coordination of Benefits; it determines which payer is primary when a patient has multiple insurance plans

COB (Coordination of Benefits) prevents duplicate payments by establishing the order in which multiple insurance plans pay a claim.

What is a CPT modifier, and when would a patient access representative need to know about it?

Answer: A two-character code appended to a CPT code to indicate that a service was altered in some way without changing its definition

A CPT modifier provides additional information about a procedure without changing its description, such as indicating a bilateral procedure or a service performed by a different provider.

What does 'CMS' stand for in the US healthcare system?

Answer: Centers for Medicare & Medicaid Services

CMS (Centers for Medicare & Medicaid Services) is the federal agency within HHS that administers Medicare, Medicaid, CHIP, and the Health Insurance Marketplace.

What is the key difference between 'inpatient' and 'outpatient' status for billing purposes?

Answer: Inpatient requires a formal physician admission order for overnight stay; outpatient services are provided without a formal admission

Inpatient status is based on a physician's order for admission with an expectation of at least two midnights of care, while outpatient services are provided without a formal hospital admission.