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UHB 5
glossary
| Term | Definition |
|---|---|
| accept assignment | an agreement between the hospital and payer that states the hospital will accept the approved amount or prospective payment rate as payment in full. |
| accounts receivable (A/R) management | refers to functions required to monitor and follow-up on outstanding accounts to ensure that reimbursement is received in a timely manner, aka collections |
| ambulatory payment classifications (APC) | Outpatient Prospective Payment System (OPPS) reimbursement method used by medicare & other government programs to provide reimbursement for hospital outpatient services. under APC system, hospital is paid a fixed fee |
| ambulatory surgery | surgery that is performed on the same day the patient is discharged. Ambulatory surgery may be performed in a freestanding or hosptial-based ambulatory surgery setting |
| billing process | functions required to prepare charges for submission to patients and third-party payers to obtain reimbursement for hospital services |
| capitation | reimbursement method that provides payment of a fixed amount, paid per member per month |
| case mix | a term used to describe type of patient cases treated by the hospital |
| case rate | a reimbursement method that provides a set payment rate to the hospital for a case. the payment rate is based on the type of case and resources required to treat the patient |
| charge description master (CDM) | computerized system used by the hospital to inventory and record services and items provided by the hospital. AKA CHARGEMASTER |
| claims process | the portion of billing that involves preparing claims for submission to payers |
| clean claim | a claim that does not need to be investigated by the payer. a clean claim passes all internal billing edits and payer specific edits and is paid without the need for additional information |
| clearinghouse | an organization that receives claim information from hospitals and other providers in various formats for conversion to a required format for submission to various payers |
| CMS 1450 (UB-04) | uniform hard copy of the claim form used by instutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement |
| CMS-1500 | the claim form used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement |
| collections | involves monitoring accounts that are outstanding and pursuing payment of those balances from patients and third-party payers. Collections aka A/R |
| contract rate | a reimbursement method that provides a set payment rate to the hospital as agreed to by the hospital and payer |
| Detailed itemized statement | a listing of all charges incurred during the patient visit |
| dirty claim | a claim hat doesnt pass payer internal billing edits or payer-specific edits and requires investigation by the payer |
| Electronic data interchange EDI | term used to describe the process of sending information from one place to another via computer |
| encoder | a computer program used to assist with code assignment |
| facilit charges | charges that represent the cost and overhead for providing patient care services, including space, equipment, drugs and biologicals, and technical staff; tech component of services |
| fee-for-service | reimbursement method that provides payment for hospital services based on an established fee schedule for each service |
| fee schedule | a listing of established allowed amounts for specific medical services and procedures |
| flat rate | a reimbursement method whereby the hospital is paid a set payment rate for a hospital admission regardless of charges accrued |
| form locator FL | name used to refer to each of the 81 fields on the CMS 1450 (UB-04) |
| grouper | computer program used for the assignment of an MS-DRG or APC based on the information entered such as diagnosis, procedure, and other patient information such as age, sex and length of stay |
| inpatient prospective payments system (IPPS) | Prospective Payment System(PPS) est. as mandated by the Tax equity and fiscal responsibiliy act (TEFRA) in '83 to provide reimbursement for inpatient services. |
| MS-DRG medicare severity-diagnosis related group | System implemented under IPPS; used by medicare and other government programs to provide reimbursement for inpatient services. Replaced DRG in 2007. Hospital is paid a fixed fee based on severity of the patient's condition and related treatment |
| Outpatient Prospective Payment System (OPPS) | prospective payment system implemented in august 2000 by CMS that provides reimbursement for hospital outpatient services. system implemented under OPPS is known as Ambulatory Payment Classifications (APC) |
| Participating provider agreement PAR | written agreement between the hospital and a payer that outlines the terms and conditions of participation for the hospital and payer |
| patient invoice | document prepared by the hospital to advise the patient of an outstanding balance that includes details regarding current services. It is generally sent out the first time a balance is billed to the patient. |
| Patient statement | a document prepared by the hospital that provides details regarding account activity, including the previous balance, recent charges, payments, and the current balance. statement is generally sent monthly to notify the patient of a balance due. |
| per diem | reimbursement method that provides payment of a set rate, per day to the hospital, rather than payment based on total charges |
| percentage of accrued charges | reimbursement method that calculates payment for charges accrued during a hospital stay. payment is based on a percentage of approved chargess |
| professional charges | charges the represent the professional component of patient care services performed by physicians and other non-physician clinical providers |
| reimbursement | term used to describe the amount paid to the hospital, for services rendered, by patients or third-party payers |
| relative value scale RVS | reimbursement method that assigns a relative value to each procedure. It represents work, practice expense, and cost of malpractice insurance and is assigned to each professional service code |
| Remittance advice RA | a document prepared by the payer that provides an explanation and details regarding the payer;'s payment determination for charges submitted |
| Resource-based relative value scale RBRVS | a payment method used by Medicare and other government programs to provide reimbursement for physician and some outpatient services. Consists of a fee schedule of approved amounts calculated based on relative values for each procedure |
| revenue code | four-digit number assigned to each service or item provided by the hospital that designates the type of service or where the service was performed |
| third-party payer | an organization or other entity that provides coverage for medical services, such as insurance companies, managed care plans, medicare, and other government programs |
| timely filing | refers to the period of time in which claims must be filed, such as 90 days. Timely filing is generally calculated from the date of service. |
| Usual, customary, and reasonable (UCR) | reimbursement method whereby payment is determined by reviewing three fees : usual, customary, and reasonable |
| Usual fee | usually submitted by the provider of a service or item |
| Customary Fee | fee providers of the same specialty in the same geographic area charge for a service or item |
| Reasonable fee | fee that is considered reasonable |
Created by:
zombiewho
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