Question | Answer |
ABN - Advance Beneficiary Notice | A form used to notify patients in advance that a service may not be covered and the patient may be responsible. |
Approved Amount | the amount an insurance carrier deems rasonable fo the billed charges. |
Assigned Claims | a claim form that directs payment to the provider/supplier. |
Assignment of Benefits | authorization for the insurance coompany to send insurance payments directly to the health care provider also, an agreement with Medicare tht 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 recieve insurance benefits. |
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-Insureance | the Meicare co-pay paid by the patient for services. It is sometimes referred to as a copayment. |
Deductible | the amount that must be paid by a beneficiary before an insurer begins to pay for medical services. |
Diagnostic-Related Groups (DRG) | classification of diagnoses used to determine hospital payment for Medicare impatients. |
Fee Schedule | a physician's listing of all reimbursement fees for all procedures performed in the practice. |
HICN - Health Insurance Claim Number | a ten to eleven digit number assigned by Medicare to its beneficiaries. |
Medicaid | provides health coverage for the categorically needy. |
Medicare | primaryily for people older than 65 and others eligible for social Security; federal insurance program established in 1965 under ssa |
Medicare Managed Care Plans | these are health care choices such as HMO's Part C of the Medicare program. |
Non-participating Physician | a physician who has not entered into a written agreement with an insurance company to accept the plan's fee for services rendered. |
Participating Physician | a physician who has entered into a written agreement with an insurance company to accept the plan's fee for service rendered a payment in full. |
Premium | a dollar amount the insured person pays for insurance coverage. |
Resources-Based Relative Value System/Scale (RBRVS) | a system that calculates physician reimbursement for services using relative value units. |
Remittance Notice | paper summarized statement for providers including payments/rejections for one or more beneficiaries |
Medicare part A | Hospital, home healthcare, hospice, skilled nursing facilities |
Medicare part B | medical,outpatient hospital care, medical equipment, physician services, other medical services, |
One form of insurance abuse is | submitting a claim for unnecessary procedures |
To be eligible for Medicare part C you must have | Part A & B or medicare |
What is medicare part D | prescription drug program provided by private companies. |
What is a contractual write off | difference between the actual charge and the allowed amount. |
What is Utilization Review | is a review of individual cases by a committee to ensure services are medically necessary and to study how providers us medical resources. |
Allowed Charges | The moset the payer will pay any provider for services. - cannot bill the patient for the difference |
Contracted Fee Schedule | Fixed fee schedule - percentage of charges if any the patient owes and the what the payer covers - can bill the patient. |
Capitation | a fixed prepayment - non covered services can be billed. |