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Med. Billing Terms

Medical Insurance Terms-Winter 1-17

ABN-Advance Beneficiary Notice Form used to notify patients in advance that a service may not be covered and the patient may be responsible
Actual Charge The amount a physician or supplier actually bills a patient for a particular service or supply
Appeal complaint beneficiaries make if they disagree with any decision about their health care services
Appellant an individual who appeals a claim decision.
Approved Amount The amount an insurance carrier deems reasonable for the billed charges.
Assigned Claims a claim form that directs payment to the provider/supplier.
Assignment of Benefits Authorization for the insurance company to send insurance payments directly to the health care provider, also, an agreement with Medicare that the provider will accept the remittance as full payment.
Audit process to ensure that Medicare reimburses providers based only on cost associated with patient care
Beneficiary a person eligible to receive insurance benefits
Claim request for payment for Medicare benefits or services rendered by a provider.
CMS Ceters for Medicare and Medicaid Service-administers and oversees the medicare program and a portion of the state Medicaid program
COB-Coordination Of Benefits a program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan.
Co-Insurance The medicare co-pay paid by the patient for services. it is sometimes referrred to as a co-payment
CPT-Current Procedureal Terminology system of uniformed medical procedure codes to identify specific health care services
Deductible the amount that must be paid by a beneficiary before an insurere begins to pay for medical services
Diagnostic-Related Groups (DRG) classification of diangoses used to determine hospital payment for medicare inpatients
ESR-End Stage Renal Disease Kidney failure that is severe enough to require lifetime dialysis or kidney transplant
Utilization Review review of individual cases by a committee to ensure services are medically necessary and to study how providers use medical resources
Created by: d.holifield