Your FREE CBCS Flashcards 2026 – 200+ Cards

A claim with no errors or missing information that passes edits and can be processed and paid on the first submission.

The standard claim form used by physicians and other non-institutional (professional) providers; electronic equivalent is the 837P.

The institutional claim form (also called the CMS-1450) used by hospitals and facilities; electronic equivalent is the 837I.

Another name for the UB-04 institutional/hospital claim form.

A claim stopped before processing for a format or data error; it is corrected and resubmitted (it never entered the payer's system).

A claim the payer processed but refused to pay; it is corrected and formally appealed (not simply resubmitted).

A claim held by the payer for review or additional information before adjudication.

The statement a payer sends the provider explaining how each claim line was paid, adjusted, or denied.

The electronic (HIPAA 835) version of a remittance advice sent to the provider.

The statement a payer sends the patient showing how a claim was processed; it is not a bill.

Claim Adjustment Reason Code — a standardized code on a remittance advice explaining why a payment was adjusted.

Remittance Advice Remark Code — a supplemental code giving additional explanation alongside a CARC.

A formal request asking a payer to reconsider a denied or underpaid claim, with supporting documentation, within the timely-filing window.

The deadline by which a claim or appeal must be submitted; missing it usually forfeits payment.

The first level of the Medicare fee-for-service appeals process, performed by the claims contractor.

A service that receives electronic claims, validates and reformats them, and routes them to the correct payer.

The electronic claim transaction for professional (physician) services — the electronic CMS-1500.

The electronic claim transaction for institutional (facility) services — the electronic UB-04.

The field on the CMS-1500 where ICD-10-CM diagnosis codes are entered (up to 12).

The field where the CPT/HCPCS procedure code and any modifiers are entered.

The CMS-1500 block 24E entry that links each service line to its supporting diagnosis in block 21.

The field for the billing provider's name, address, and NPI.

A reimbursement model paying the provider for each individual service rendered.

A reimbursement model paying the provider a fixed amount per member per month regardless of services used.

A model paying a predetermined amount per case or service group, such as Medicare's DRGs and APCs.

Diagnosis-Related Group — the inpatient classification that pays a fixed amount per admission.

Ambulatory Payment Classification — the unit of payment for hospital outpatient services under OPPS.

The maximum a payer will pay for a covered service; the contracted or fee-schedule rate.

The contractual adjustment a provider must remove from the bill — the difference between the charge and the allowed amount.

Billing the patient for the difference between the provider's charge and the payer's allowed amount; often prohibited for in-network/Medicare.

The process of recording the services and items provided so they can be billed.

Software that checks a claim for errors and edits before submission to produce a clean claim.

The money owed to a provider for services billed but not yet paid.

A report grouping outstanding A/R by how long it has been unpaid (e.g., 0-30, 31-60 days).

A daily record of charges, payments, and adjustments for a provider's patients.

An itemized form listing the services and diagnoses for an encounter, used to generate the claim.

Electronic Data Interchange — the electronic exchange of claim and remittance data between providers and payers.

A claim automatically forwarded from Medicare to a secondary payer (e.g., Medigap) after Medicare pays.

Filing claims in the correct primary-then-secondary order when a patient has more than one plan.

A payer reducing a code to a lower level because documentation or the claim does not support the level billed.

The Fair Debt Collection Practices Act, which governs how patient balances may be collected.

A third party engaged to collect overdue patient balances under fair-debt rules.

The bill sent to a patient showing the balance due after insurance has paid.

The payer's process of reviewing a claim and deciding payment, adjustment, or denial.

The payment a provider receives from a payer or patient for services rendered.

A claim with errors or missing information that cannot be processed and is rejected or returned.

Supporting documentation (e.g., operative notes) submitted with a claim when required.

A unique 10-digit number identifying a health-care provider on claims.

The employer or provider identification number used for billing and tax reporting.

A code on the CMS-1500 indicating where a service was rendered (e.g., 11 = office).

A code on the UB-04 identifying the type of service or department (e.g., room, pharmacy).

A UB-04 code describing a condition affecting payer processing of the claim.

A UB-04 code reporting amounts or values necessary to process the institutional claim.

A UB-04 code reporting a significant event and date affecting the claim.

A four-digit UB-04 field identifying the facility type and bill classification.

Recording payer and patient payments and adjustments against the patient's account.

The amount a participating provider writes off per the payer contract.

A patient balance deemed uncollectible after collection efforts.

Money returned to a patient or payer after an overpayment is identified.

Payment exceeding the amount due; must be refunded or applied appropriately.

The second level of the Medicare appeals process, performed by a Qualified Independent Contractor.

The third level of the Medicare appeals process, a hearing before an ALJ.

A private contractor that processes Medicare claims for a region.

A claim submitted electronically (837) rather than on paper.

A claim submitted on a physical form (CMS-1500 or UB-04).

A group of claims submitted together to a clearinghouse or payer.

A clearinghouse or payer report confirming whether claims were accepted or rejected.

A metric of how long, on average, it takes to collect payment after billing.

The percentage of billed charges actually collected by the practice.

A set per-member-per-month payment under a managed-care contract.

A change to a charge or payment, such as a write-off or correction.

A record of all charges, payments, and adjustments for a single patient.

An electronic request (276/277) asking a payer the status of a submitted claim.

Sending a corrected rejected claim back to the payer for processing.

A payer payment that is less than the contracted allowed amount.

The U.S. code set for reporting diagnoses and the reasons for an encounter, used in all settings.

Current Procedural Terminology — the AMA code set for physician and outpatient procedures and services.

Codes for supplies, drugs, equipment, and services not covered by CPT.

A two-character CPT/HCPCS addition giving detail about a service (bilateral, distinct, repeat); can change payment.

The principle that a service must be reasonable and necessary; the diagnosis must support the procedure billed.

National Correct Coding Initiative edits — automated checks that block improper code pairs and unbundling.

Reporting components of a service separately to get higher payment when one combined code applies — non-compliant.

Assigning a higher-level or more expensive code than the documentation supports — fraud.

The part of the ICD-10-CM book where the coder first locates the main term for a condition.

The part of the ICD-10-CM book where the coder verifies the code and reads its instructional notes.

An ICD-10-CM convention meaning the two conditions are never coded together.

An ICD-10-CM convention meaning the condition is not included here but both may be coded if present.

An ICD-10-CM instruction to sequence an underlying condition before the current code.

An ICD-10-CM instruction to add a secondary code to fully describe the condition.

An ICD-10-CM character required by some categories (e.g., to show the encounter type for an injury).

The ICD-10-CM 'X' used to fill empty character positions so a required 7th character lands correctly.

Not Elsewhere Classifiable — used when a specific code does not exist for a documented condition.

Not Otherwise Specified — the equivalent of 'unspecified' when documentation lacks detail.

ICD-10-CM detail specifying right, left, or bilateral for a paired body part.

Evaluation and Management CPT codes used to report office and other patient visits.

The main CPT codes for widely used procedures and services (five digits).

Optional CPT tracking codes for performance measurement.

Temporary CPT codes for emerging technologies, services, and procedures.

A significant, separately identifiable E/M service by the same provider on the same day as a procedure.

Indicates a bilateral procedure (performed on both sides).

A distinct procedural service, separate from another service performed the same day.

Combining related services into a single code, as required by NCCI edits.

The condition established after study to be chiefly responsible for an inpatient admission.

In outpatient coding, the main reason for the encounter, sequenced first.

Listing codes in the correct order — the principal/first-listed diagnosis first.

An ICD-10-CM code used when the reason for the visit is a routine exam, not a complaint.

Codes assigned when no definitive diagnosis is documented for an outpatient encounter.

Connecting each procedure code to the diagnosis that justifies it on the claim.

Extracting the diagnoses, procedures, and data needed for coding from the health record.

'Probable/suspected' conditions are NOT coded for outpatient encounters; code the documented signs/symptoms.

The patient's stated reason for the visit, in their own words.

A rule (abbreviation, punctuation, symbol, or note) governing correct code assignment.

In a code title, 'and' is interpreted as 'and/or'.

In the index and tabular, 'with' means associated or due to, and links the conditions.

The ICD-10-CM code listed next to the main term, used when no further detail is documented.

A coding convention requiring the underlying cause to be sequenced before the manifestation.

A single ICD-10-CM code reporting two diagnoses, or a diagnosis with a complication.

A CPT code reported with a primary procedure code, never alone.

A CPT code for a service with no specific code, requiring a report.

A CPT concept bundling pre-, intra-, and post-operative care into the surgery code.

A service whose payment is included in another service and not billed separately.

Professional component — the physician's interpretation portion of a service.

Technical component — the equipment/facility portion of a service.

Multiple procedures performed at the same session.

Repeat procedure or service by the same physician.

An ABN is on file for a service expected to be denied by Medicare.

A HCPCS Level II code reporting injectable and other drugs.

A HCPCS Level II code reporting durable medical equipment.

A code for encounters with circumstances other than disease or injury (e.g., screening).

An ICD-10-CM code describing how an injury occurred; never sequenced first.

When both are documented and indexed separately, code both, sequencing acute first.

An error — the index must be confirmed in the Tabular List before coding.

Using the most precise code the documentation supports (e.g., full laterality and detail).

A coexisting condition that affects patient care and may be coded as secondary.

Software that helps a coder find and assign correct codes.

A MAC's policy on whether a service is covered in its region.

A nationwide Medicare policy on whether and when a service is covered.

An NCCI edit capping the units of a service allowed per patient per day.

Assigning only codes supported by documentation, following official guidelines.

The rules that determine which plan pays first when a patient has more than one insurance plan.

For a dependent child with two plans, the parent whose birthday falls earlier in the year is primary.

The plan that pays first on a claim before any other coverage.

The plan that pays after the primary, often covering remaining balances.

Health Maintenance Organization — managed care requiring in-network providers and usually PCP referrals.

Preferred Provider Organization — managed care allowing out-of-network care without a referral at higher cost.

Exclusive Provider Organization — covers only in-network care but typically without referrals.

Point-of-Service plan — combines HMO and PPO features; referrals for some out-of-network care.

A fee-for-service plan letting the patient see any provider, usually with higher out-of-pocket cost.

The federal program for people 65+ and certain others: Parts A, B, C, and D.

Covers inpatient hospital, skilled nursing, and hospice care.

Covers physician services, outpatient care, and durable medical equipment.

Medicare Advantage — Parts A and B (and often D) delivered through private plans.

Covers prescription drugs through private plans.

A private supplemental policy covering deductibles and coinsurance left by Medicare A and B.

The joint federal-state program for low-income individuals; generally the payer of last resort.

The federal health program for active-duty and retired military members and their families.

The Children's Health Insurance Program for children in families above Medicaid limits.

Insurance covering work-related injuries and illness; a liability/third-party payer.

The patient's authorization for the payer to pay the provider directly.

A primary care physician's authorization for a patient to see a specialist (common in HMOs).

Confirming that a service is covered by the payer before it is provided.

Payer approval required before a service or drug is provided.

An estimate of what the payer will cover for a planned service before it is done.

Confirming a patient's active coverage and benefits before a visit.

A fixed dollar amount a patient pays for a covered service at the time of care.

The amount a patient pays out of pocket each year before the plan begins to pay.

The percentage of a covered service's cost the patient pays after the deductible.

The annual cap after which the plan pays 100% of covered services.

A limit on patient out-of-pocket spending after which the plan pays in full.

The amount paid (often monthly) to maintain insurance coverage.

A patient without insurance who is responsible for the full cost of care.

CMS-R-131 notice telling a Medicare patient a service may be denied and they may owe for it.

A provider not contracted with the patient's plan, usually paid at a lower rate or not at all.

A provider contracted with a payer, agreeing to its allowed amounts.

Documentation showing the member's plan, ID, group number, and payer contact for verification.

The person covered by an insurance plan and entitled to its benefits.

The person responsible for paying a patient's bill (may differ from the patient).

The identifier on an insurance card linking the member to an employer or plan group.

The primary policyholder under whom dependents are covered.

A spouse or child covered under the subscriber's plan.

The date a patient's insurance coverage begins.

The date a patient's insurance coverage ends.

The period when individuals may enroll in or change insurance plans.

A payer's list of covered prescription drugs.

A plan paying providers a fixed amount per member regardless of services used.

The primary care physician in an HMO who must authorize specialist care.

The maximum amount a plan considers payable for a covered service.

A provider not contracted with a payer; may balance-bill where allowed.

Medicaid pays only after all other available coverage has paid.

A patient covered by both Medicare and Medicaid.

A third plan that pays after primary and secondary coverage.

COB rules determining how a child's coverage is ordered between parents' plans.

Confirming what services a plan covers and the patient's cost share.

The approval number a payer issues that must appear on the claim.

The quarterly statement Medicare sends beneficiaries listing claims and payments.

A federal health program for families of veterans with service-connected disabilities.

A high-deductible plan covering essential benefits after a large out-of-pocket amount.

The financial process tracking a patient encounter from scheduling through coding, billing, payment, and collections.

Pre-service tasks: scheduling, registration, eligibility verification, and authorizations.

Post-service tasks: claim submission, payment posting, denials, appeals, and collections.

The Health Insurance Portability and Accountability Act, protecting health information via Privacy and Security Rules.

Protected Health Information — individually identifiable health information protected under HIPAA.

The HIPAA rule governing the use and disclosure of protected health information.

The HIPAA rule protecting electronic protected health information (ePHI).

The HIPAA principle of using or disclosing only the least PHI needed for a purpose.

Treatment, Payment, and health-care Operations — disclosures permitted without separate authorization.

The law that strengthened HIPAA enforcement and added breach-notification requirements.

The HITECH requirement to notify individuals and HHS after a breach of unsecured PHI.

A vendor that handles PHI for a covered entity and must comply with HIPAA.

Knowingly and intentionally submitting false claims for payment — e.g., billing for services not rendered.

Improper billing practices causing unnecessary cost, without proven intent to deceive.

The federal law imposing penalties for submitting false claims to the government.

The law prohibiting physician self-referral for certain services to entities they have a financial interest in.

The law prohibiting payment to induce referrals for services paid by federal health programs.

Office of Inspector General — the HHS office that investigates fraud, waste, and abuse.

A formal program to prevent, detect, and correct fraud, abuse, and billing errors.

The OIG process letting providers voluntarily report and resolve potential fraud or abuse.

Recovery Audit Contractor — a CMS contractor that reviews claims to recover improper Medicare payments.

Zone Program Integrity Contractor — a CMS contractor that investigates potential Medicare fraud.

A patient's agreement to a treatment after being told its risks, benefits, and alternatives.

Consent inferred from a patient's actions or circumstances (e.g., an emergency).

A review of claims and documentation to verify accuracy and compliance.

The federal law regulating how debts, including patient balances, may be collected.

A patient's signed permission to use or disclose PHI for purposes beyond TPO.

A health plan, clearinghouse, or provider that transmits health information electronically and must follow HIPAA.

Patterns such as duplicate billing, services not rendered, or upcoding that suggest fraud.

The document informing patients how their PHI may be used and disclosed.

The service phase: clinical documentation and assigning diagnosis and procedure codes.

Collecting demographic and insurance information at the start of an encounter.

Patient identity data (name, DOB, address) collected at registration.

A document capturing the services and diagnoses for a visit (similar to a superbill).

The records a covered entity uses to make decisions about an individual under HIPAA.

Health data with identifiers removed so it is no longer PHI.

Releasing PHI outside the entity that holds it.

Sharing or handling PHI within the entity that holds it.

A patient's HIPAA right to inspect and obtain a copy of their health information.

A patient's HIPAA right to a list of certain disclosures of their PHI.

A fine imposed for HIPAA or False Claims Act violations.

A False Claims Act provision letting a whistleblower sue on the government's behalf.

A self-review of coding and billing accuracy within the organization.

A review of claims by an outside payer or contractor (e.g., a RAC).

An OIG agreement a provider follows after resolving fraud allegations.

The ethical standards staff follow as part of a compliance program.

A serious, unexpected occurrence that triggers review and possible reporting.

The duty to protect a patient's health information from unauthorized disclosure.