Describe How The Patient'S Insurance Eligibility Is Confirmed

Question: The process of obtaining the dollar amount approved for a medical procedure or service before the procedure or service is scheduled.

Answer: Precertification

Question: Obtained from health insurance companies and gives the provider approval to render the medical service.

Answer: Preauthorization

Question: The electronic transfer of data (e.g. electronic claims) between two or more entities.

Answer: Electronic data interchange

Question: A process done prior to claims submission to examine claims for accuracy and completeness.

Answer: Audit

Question: A contract between a provider and an insurance company in which the health plan pays a monthly fee per patient while the provider accepts the patient’s copay as payment in full for office visits.

Answer: Capitation agreements

Question: The process of obtaining the dollar amount approved for a medical procedure or service before it is scheduled.

Answer: Precertification

Question: Form used by most health insurance payers for claims submitted by providers and suppliers.

Answer: CMS-1500

Question: Process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically.

Answer: Direct billing

Question: A healthcare provider who has signed a contract with a health insurance plan to accept lower reimbursements for services in return for patient referrals.

Answer: Participating provider

Question: An intermediary that accepts the electronic claim from the provider, reformats the claim to the specifications outlined by the insurance plan, and submits claim.

Answer: Claims clearinghouse