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link 6 ch 9
| Question | Answer |
|---|---|
| An evaluation done by a group of unbiased practicing physicians to judge the effectivness and efficiency of professional care rendered. | peer review |
| what document is issued stating the status of the claim, that is, paid, adjusted, suspended, rejected or denied. | ecplanation of benefits (EOB) |
| What claim is one that is processed by a third-party payer bur is held in an indeterminate state about payment either because of error or the need for sdditional info from the provider of service or the patient. | suspended claim |
| RA | remittance advice |
| This is also referred as remittance advice, check voucher, or payment voucher | EOB |
| This claim means payment is overdue from nonpayer. | delinquent claim |
| Nonpayment can be caused because of errors or the need for additional information in which the claim is under. | review or suspense |
| This claim is a submitted claim that does not follow specific third-party payers instructions or contains a technical error is known as | rejected claim |
| This claim is one that may be denide because of benefits coverage policy issues or program issues. | denied claim |
| What is a request for payment by asking for a review of an insurance claim that has been inadiquately or incorrectly paid or denied by an insurance company | appeal |
| This is most often referred to as a follow-up or tracer which is a request made to an insurance company to either locate the stauts of an claim, inquier about payment, or ask about general info such as deductible or entitlement. | inquiry |
| What is a sum of money paid by the third-party payer or patient the the provider of service that is more than the bill or more than the allowed amount. | overpayment |
| Medicare program appeals are referred to as | redetermination |
| ALJ | administrative law judge |
| MAC | medicare appeals council |
| FTC | federal trade commission |
| If a complaint arises about an insurance policy, medical claim, or insurance agent or broker this department should be contacted | insurance commission or the state |
| Who can hold a hearing to determine whether licensed insurers, agents, or brokers are in compliance with the inaurance laws of the state, but does not have the authority vested in a court or law to order an insurance company to make payment on a claim | insurance commissioner |
Created by:
maryce
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