Term | Definition |
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 build 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 and 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 healthcare provider also, an agreement with Medicare that the provider will accept the remittance as full payment. |
Audit audit | process to ensure that Medicare reimburses providers based only on costs associated with patient care. |
Beneficiary | a person eligible to receive insurance benefits |
claim | request for payment of Medicare benefits or services rendered by a provider. |
CMS -Centers for Medicare and Medicaid Services | administers and oversees the Medicare program and a portion of the state Medicaid program |
COB- coordination of benefits | a program for determining which health insurance pays for services first when a beneficiary is covered by more than one health care plan. |
coinsurance | d Medicare copay paid by the patient for services. It is sometimes referred to as a copayment. |
CPT current Procedural Terminology | system of uniforms medical procedure codes to identify specific health care services. |
Deductible | the amount that must be paid by a gun official Harry before an insurer begins to pay for medical services |
diagnostic related groups DRG | classification of diagnosis used to determine hospital payment for Medicare inpatients |
ESR end stage renal disease | kidney failure that is severe enough to require lifetime dialysis or a kidney transplant. |