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