Health Insurance Today Chapter 9 Terms
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| adjudicated | How the decision was made regarding the Payment of an insurance claim
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| advanced beneficiary notice (ABN) | A form that Medicare requires all healthcare providers to use when Medicare does not pay for a service. Patients must sign the form to acknowledge that they understand they have a choice about healthcare in the event that Medicaid doesn't pay
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| beneficiary | An individual who has health insurance through Medicare, Medicaid, or TRICARE Programs
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| benefit period | the duration of time during which a Medicare beneficiary is eligible for Part A benefits for services incurred in a hospital or a skilled nursing facility (SNF) or both. A benefit period begins the day an individual is admitted to a hospital or an SNF
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| Clinical Laboratory Improvement Act (CLIA) | A program that Congress established in 1988 to regulate quality standards for all lab testing done on humans to ensure safety, accuracy, reliability, and timeliness of patient test results regardless of where the test was performed
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| coordination of benefits contractors | An individual who ensures that the information on Medicare's eligibility database regarding other health insurance primary to Medicare is up-to-date & accurate
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| crosswalks | The process of matching one set of data elements or category of codes to their equivalents within a new set of elements or codes
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| downcoding | When claims r submitted w out-dated, deleted, or nonexistent CPT codes, and the payer assigns a sub code it thinks best fits services performed, resulting n a decreased pymnt. Can result when Evaluation & Mgmnt serv levels doesn't match diagnostic codes
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| dual eligibles | Patients who are eligible for Medicaid & Medicare coverage (Medi-Medi)
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| electronic Medicare Summary Notice (MSN) | A quick & convient way for beneficiaries to track their claims that allow beneficiaries to look at their Medicare Summary Notice on the web and print copies from their home computers
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| end-stage renal disease (ESRD) | Permanent kidney disorders requiring dialysis or transplant
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| electronic remittance advice (ERA) | One of several diff. types of electronic formats rather than a paper document. Pymnts can be posted automatically to petients' accts, allowing health ins professionals to update accts receivable faster & more accurately than posting pymnts manually
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| electronic funds transfer (EFT) | A system wherein $ is moved electronically between accts & Orgz. in this case of ins claims r submitted electr., many carriers transfer pymnts directly into provider's bank acct rather than mailing check, makin funds instantly usuable
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| Federal Insurance Contribution Act (FICA) | Act that provides for a Federal system of old-age, survivors, disability, & hospital insurance
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| Health Insurance Claim Number (HICN) | A number assigned to Medicare beneficiary that allows the health insurance professionals 2 look @ the patient's ID card & immediately determine level of coverage. The # is in the format of 9 digits, usually benef. SSN, followed by one alpha character
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| Health Care Quality Improvement Program | A program created to improve health outcomes of all Medicare beneficiaries regardless of personal characteristics, physical location, or setting
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| lifetime (one-time) release of information form | A form that the beneficiary may sign, authorizing a lifetime release of information, instead of signing an information release form annually.
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| local coverage decisions (LCDs) | ** Medical-necessity documents that focus exclusively on whether a service is reasonable and necessary according to the ICD-9-CM code for that particular CPT procedure code
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| local medical review policies (LMRPs) | Policies that outline general provisions for the acceptance or rejection of Medicare claims.
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| Medicare Beneficiary Protection Program | A Medicare quality-improvement organization that helps protect the safety and health of Medicare beneficiaries through numerous activities such as responses to beneficiary complaints, Hospital Issued Notice of Noncoverage and Notice of Discharge
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| Medicare gaps | The uninsured areas under Medicare with which elderly and disabled Americans need additional help
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| Medicare HMOs | Consists of a network of physicians and other healthcare providers. Members/enrollees must receive care only from the providers in the network except in emergencies. The least expensive and most restrictive Medicare managed care plan
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| Medicare limiting charge | In the original Medicare plan, the highest amount of money a Medicare beneficiary can be charged for a covered service by physicians and other healthcare suppliers who do not accept assignment. The limiting charge is 15% over Medicare’s “approved amount.”
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| Medicare managed care plan | A health maintenance organization or preferred provider organization that uses Medicare to pay for part of its service for eligible beneficiaries. It provides all basic Medicare benf, + some add. coverages (depends on plan) 2fill gaps Medicare don't pay
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| Medicare nonparticipating provider (nonPAR) | Provider or supplier who has not signed a contract with Medicare and may choose whether to accept Medicare’s approved amount as payment on a case-to-case basis. If they do not accept the approved amount, the beneficiary pays the full billed amount.
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| Medicare participating provider (PAR) | Provider or supplier who has signed a contract with Medicare and agrees to accept Medicare’s allowed amount as payment in full.
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| Medicare Part A | Hospital insurance. Helps pay for medically necessary services, including inpatient hospital care, inpatient care in a skilled nursing facility, home healthcare, and hospice care.
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| Medicare Part A fiscal intermediary (FI) | private organization that contracts with Medicare to pay Part A and some Part B bills. Determines payment to Part A facilities for covered items and services provided by the facility.
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| Medicare Part B | Medical (physicians’ care) insurance financed by a combination of federal government funds and beneficiary premiums.
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| Medical Part B carrier | A private company that contracts with Centers for Medicare and Medicaid Services to provide claims processing and payment for Medicare Part B services.
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| Medicare Part B Crossover Program | A fee-per-claim service that Medicare Part B offers to private insurers and retirement plans.
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| Medicare Part C (Medicare Advantage Plans) | Prepaid healthcare plans that offer regular Part A and Part B Medicare coverage in addition to coverage for other services. Formerly called Medicare+Choice.
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| Medicare Part D (prescription drug plan) | Pays portion of prescription drug expenses and cost sharing for qualifying individuals.
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| Medicare Secondary Payer (MSP) | The term used when Medicare is not responsible for paying first when the beneficiary is covered under another insurance policy
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| Medicare Summary Notice (MSN) | A monthly statement that the beneficiary receives from Medicare after a claim is filed. The statement lists Part A and Part B claims information, including the patient’s deductible status.
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| Medicare supplement policy | A health insurance plan sold by private insurance companies to help pay for healthcare expenses not covered by Medicare and its deductibles and coinsurance.
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| peer review organization (PRO) | Groups of practicing healthcare professionals who are paid by the federal government to evaluate the care provided to Medicare beneficiaries in each state and to improve the quality of services.
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| Program of All-Inclusive Care for the Elderly (PACE) | A program that provides comprehensive alternative care for noninstitutionalized elderly individuals, 55 years and older, who would otherwise be in a nursing home
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| prospective payment system (PPS) | Medicare’s reimbursement system for inpatient hospital costs based on predetermined factors and not on individual services. Rates are set at a level intended to cover operating costs for treating a typical inpatient in a given diagnosis-related group.
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| Provider-sponsored organization (PSO) | group of medical providers—physicians, clinics, and hospitals—that skips the insurance company middleman and contracts directly with patients. Members pay a premium and a copayment each time a service is rendered
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| Quality improvement organizations (QIO) | A program that works with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to ensure patients get the right care at the time, particularly among underserved populations. the program also safeguards the integrity of th
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| resource-based relative value system | reimbursement system designed to address the increasing cost of healthcare in the United States and try to resolve the inequities between geographic areas, time in practice, and the current payment schedule. Replaces the Medicare fee system.
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| trading partner agreement | A formal contract between Medicare Part B and supplemental insurer.
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