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Health Ins Final

Medical Necessity involves linking every procedure or service code reported on an ins. claim to a condition code that justifies the need to perform that procedure or service
beneficiary the person eligible to receive health benefits
CPT current procedural terminology
HCPCS healthcare common procedure coding system
chargemaster hospital encounter form
ICD9CM international classification of disease 9th edition clinical modification
explanation of benefits report detailing the results of a processing claim
remittance advice notice sent by the ins. company that contains payment information about a claim
Medicaid provides medical and health-related services to certain individuals and families with low incomes and limited resources
Medicare reimburses healthcare services to Americans over the age of 65
Medicare part A reimburses institutional providers for inpatient, hospice, and some home health services
Medicare part B reimburses institutional providers for outpatient services and physicians for inpatient office services
Medicare part C included managed care and private fee-for-service plans that provided contracted care to Medicare patients
Medicare part D adds prescription drug coverage to the original Medicare Plan
General eligibility for Medicare 1.individuals or their spouses to have worked at least 10 years in Medicare-covered employment 2.individuals to be the min. of 65 years old 3.individuals to be citizens or permanent resident of the US
fee schedule a list of predetermined payments for healthcare services provided to patients
clean claim contains all required data elements needed to process and pay the claim
coinsurance the % of costs to patient shares with the health plan
ethics the principles of right or good conduct
limiting charge max. fee a physician may charge
HIPAA health insurance portability and accountability act: primary intent is to provide better access to health ins. limit fraud and abuse, and reduce administrative costs
fee for service reimburses providers for individual healthcare services rendered
accreditation a voluntary process that a healthcare facility or organization undergoes to demonstrate that it had met standard beyond those required by law
assignment of benefits the patient and/or insured authorizes the payer to reimburse the provider directly
accept assignment the provider agree to accept what the insurance company allows or approves as payment in full for the claim
guarantor person responsible for paying the charges
participating provider contracts with a health ins. plan and accepts whatever the plan pays for procedure or services proformed
non PAR does not contract with the ins plan; patients who elects to receive care from nonPARs will incur higher out-of-pocket expenses
birthday rule determines coverage by primary and secondary policies when each parent subscribes to a different health ins plan
claim submission the electronic or manual transmission of claim data to payers or clearinghouses for processing
clearinghouse a public or private entity that processes or facilities the processing of non-standard date elements
unbundling submitting multiple CPT codes when just one code should have been submitted
fraud intentional deception or misrepresentation that could result in an unauthroized payment
abuse actions inconsistent with accepted, sound medical, business, or fiscal practices
commercial health in covers the medical expenses of individual groups; premiums and benefits vary according to the type of plan offered
group health ins traditional healthcare coverage subsidized by employers and other organizations whereby part or all premiums costs are paid for and/or discounted groups rates are offered to eligible individuals
Medigap supplemental plan designed by the federal govn but sold by private commercial ins companies to cover the cost of Medicare deductibles, copayments, and coinsurance, which are considered "gaps" in Medicare coverage
Durable Medical equipment canes, crutches, walkers, commode chairs, blood glucose monitors, etc
AMA american medical association
CMS centers for Medicare and Medicaid services
MAC Medicare administrative contractor
HCPCS level II national codes published by CMS, which include 5 digit alphanumerical codes for procedures, services, and supplies not classified to CPT
DRGS diagnosis related groups are organized into mutually exclusive categories. which are loosely based on body systems
PPS prospective payment system, issue predetermined payment for services
MMA Medicare Prescription Drug, Improvement and Modernization Act; adds new prescription drug and preventative benefits and provides extra assistance to people with low incomes
Office of Workers Compensation Program administers programs that provides wage replacement benefits, medical treatment vocational rehab and other benefits to federal workers who are injured at work or acquire an occupational disease
MSDS Material Safety Data Sheet, contains information about chemical and hazardous substances used on site
First report of INjury Worker's compensation form completed when the patient first seeks treatment for a work related illness or injury
Deposition legal proceeding during which a party answers questions under oath
CHAMPVA Civilian Health and Medical Program of the Department of Veterans Affairs, program that provides health benefits for dependants of veterans rated as 100% permanently and totally disabled as a result of service connected conditions
RUVs Relative value unit, payment components consisting of physician work, practice expense, and malpractice expense
Outliers hospitals that treat usually costly cases receive increased Medicare payments
CMS forms formerly knowns as the Health Care Financing Administration HCFA
TRICARE healthcare for active duty members of the uniformed services and their families, retirees and their families, and survivors of all uniformed services who are not eligible for Medicare
TRICARE sponsors uniformed service personnel who are either active duty, retired or deceased
TPA Third party payer
HIPAA Health Insurance Portability and Accountability Act
EHR Electronic Health Record
OIG Office of Inspector General
PCP Primary Care Provider
COB Coordination of Benefits
CMS Centers for Medicare/Medicaid services
FEP Federal Employee Program
UCR Usual customary and reasonable
ABN advance beneficiary notice
RAC recovery audit contractor
MAC Medicare Administrative contractor
NPI National Provider Indentifier
SOF signature on file
OSHA occupational safety and health administration
EDI electronic data interchange
Created by: sabrina.ray