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ANSI ASC X12N 837
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UHI ch 5
Understanding Health Insurance chapter 5
| Question | Answer |
|---|---|
| ABUSE | ACTIONS INCONSISTENT WITH ACCEPTED, SOUND MEDICAL, BUSINESS, OR FISCAL PRACTICES. |
| ANSI ASC X12N 837 | VARIABLE-LENGTH FILE FORMAT USED TO BILL INSTITUTIONAL, PROFESSIONAL, DENTAL, AND DRUG CLAIMS. |
| AUTHORIZATION | DOCUMENT THAT PROVIDES OFFICIAL INSTRUCTION, SUCH AS THE CUSTOMIZED DOCUMENT THAT GIVES COVERED ENTITIES PERMISSION TO USE SPECIFIED PROTECTED HEALTH INFORMATION (PHI) FOR SPECIFIED PURPOSES OR TO DISCLOSE PHI TO A THIRD PARTY SPECIFIED BY THE INDIVIDUAL. |
| BLACK BOX EDITS | NONPUBLISHED CODE EDITS, WHICH WERE DISCONTINUED IN 2000. |
| BREACH OF CONFIDENTIALITY | UNAUTHORIZED RELEASE OF PATIENT INFORMATION TO A THIRD PARTY. |
| CASE LAW | ALSO CALLED COMMON LAW; BASED ON A COURT DECISION THAT ESTABLISHES A PRECEDENT. |
| CHECK DIGIT | ONE DIGIT CHARACTER, ALPHABETIC OR NUMERIC, USED TO VERIFY THE VALIDITY OF A UNIQUE IDENTIFIER. |
| CIVIL LAW | AREA OF LAW NOT CLASSIFIED AS CRIMINAL. |
| CLINICAL DATA ABSTRACTING CENTER (CDAC) | REQUESTS AND SCREENS MEDICAL RECORDS FOR THE PAYMENT ERROR PREVENTION PROGRAM (PEPP)TO SURVEY SAMPLES FOR MEDICAL REVIEW, DRG VALIDATION, AND MEDICAL NECESSITY. |
| COMMON LAW | ALSO CALLED CASE LAW; IS BASED ON A COURT DECISION THAT ESTABLISHES A PRECEDENT. |
| COMPREHENSIVE ERROR RATE TESTING (CERT) PROGRAM | ASSESSES AND MEASURES IMPROPER MEDICARE FEE-FOR-SERVICE PAYMENTS (BASED ON REVIEWING SELECTED CLAIMS AND ASSOCIATED MEDICAL RECORD DOCUMENTATION). |
| CONFIDENTIALITY | RESTRICTING PATIENT INFORMATION ACCESS TO THOSE WITH PROPER AUTHORIZATION AND MAINTAINING THE SECURITY OF PATIENT INFORMATION. |
| CRIMINAL LAW | PUBLIC LAW GOVERNED BY STATUTE OR ORDINANCE THAT DEALS WITH CRIMES AND THEIR PROSECUTION. |
| CURRENT DENTAL TERMINOLOGY (CDT) | MEDICAL CODE SET MAINTAINED AND COPYRIGHTED BY THE AMERICAN DENTAL ASSOCIATION. |
| DECRYPT | TO DECODE AN ENCODED COMPUTER FILE SO THAT IT CAN BE VIEWED. |
| DEFICIT REDUCTION ACT OF 2005 | CREATED MEDICAID INTEGRITY PROGRAM (MIP), WHICH INCREASED RESOURCES AVAILABLE TO CMS TO COMBAT ABUSE, FRAUD, AND WASTE IN THE MEDICAID PROGRAM. CONGRESS REQUIRES ANNUAL REPORTING BY CMS ABOUT THE USE AND EFFECTIVENESS OF FUNDS APPROPRIATED FOR THE MIP. |
| DEPOSITION | LEGAL PROCEDING DURING WHICH A PARTY ANSWERS QUESTIONS UNDER OATH (BUT NOT IN OPEN COURT). |
| DIGITAL | APPLICATION OF MATHEMATICAL FUNCTION TO AN ELECTRONIC DOCUMENT TO CREATE A COMPUTER CODE THAT CAN BE ENCRYPTED (ENCODED). |
| ELECTRONIC TRANSACTION STANDARDS | ALSO CALLED TRANSACTIONS RULE; A UNIFORM LANGUAGE FOR ELECTRONIC DATA INTERCHANGE. |
| ENCRYPT | TO CONVERT INFORMATION TO A SECURE LANGUAGE FORMAT FOR TRANSMISSION. |
| FALSE CLAIMS ACT (FCA) | PASSED BY THE FEDERAL GOVERNMENT DURING THE CIVIL WAR TO REGULATE FRAUD ASSOCIATED WITH MILITARY CONTRACTORS SELLING SUPPLIES AND EQUIPMENT TO THE UNION ARMY. |
| FEDERAL CLAIMS COLLECTION ACT | REQUIRES MEDICARE ADMINISTRATIVE CONTRACTORS (PREVIOUSLY CALLED CARRIERS AND FISCAL INTERMEDIARIES), AS AGENTS OF THE FEDERAL GOVERNMENT, TO ATTEMPT THE COLLECTION OF OVERPAYMENTS. |
| FEDERAL REGISTER | LEGAL NEWSPAPER PUBLISHED EVERY BUSINESS DAY BY THE NATIONAL ARCHIVES AND RECORDS ADMINISTRATION (NARA). |
| FIRST LOOK ANALYSIS FOR HOSPITAL OUTLIER MONITORING (FATHOM) | DATA ANALYSIS TOOL, WHICH PROVIDES ADMINISTRATIVE HOSPITAL AND STATE SPECIFIC DATA FOR SPECIFIC CMS TARGET AREAS. |
| FRAUD | INTENTIONAL DECEPTION OR MISREPRESENTATION THAT COULD RESULT IN AN UNAUTHORIZED PAYMENT. |
| HOSPITAL INPATIENT QUALITY REPORTING (HOSPITAL IQR)PROGRAM | DEVELOPED TO EQUIP CONSUMERS WITH QUALITY OF CARE INFORMATION SO THEY CAN MAKE MORE INFORMED DECISIONS ABOUT HEALTHCARE OPTIONS. |
| HOSPITAL VALUE BASED PURCHASING (VBP) PROGRAM | HEALTHCARE REFORM MEASURE THAT PROMOTES BETTER CLINICAL OUTCOMES AND PATIENT EXPERIENCES OF CARE; EFF OCT 2012, HOSPITALS RECEIVE REIMBURSEMENT FOR INPATIENT ACUTE CARE SERVICES BASED ON CARE QUALITY (INSTEAD OF THE QUANTITY OF SERVICES PROVIDED). |
| IMPROPER PAYMENTS INFORMATION ACT OF 2002 (IPA) PART I | ESTABLISHED THE PAYMENT ERROR RATE MEASUREMENT (PERM) PROGRAM TO MEASURE IMPROPER PAYMENTS IN THE MEDICAID PROGRAM AND THE STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP); |
| IMPROPER PAYMENTS INFORMATION ACT OF 2002 (IPA) PART II | COMPREHENSIVE ERROR RATE TESTING (CERT) PROGRAM TO CALCULATE THE PAID CLAIMS ERROR RATE FOR SUBMITTED MEDICARE CLAIMS BY RANDOMLY SELECTING A STATISTICAL SAMPLE OF CLAIMS TO DETERMINE WHETHER CLAIMS WERE PAID PROPERLY; |
| IMPROPER PAYMENTS INFORMATION ACT OF 2002 (IPA) PART III | AND THE HOSPITAL PAYMENT MONITORING PROGRAM (HPMP) TO MEASURE, MONITOR, AND REDUCE THE INCIDENCE OF MEDICARE FEE FOR SERVICE PAYMENT ERRORS FOR SHORT TERM, ACUTE CARE AT INPATIENT PPS HOSPITALS. |
| LISTSERV | SUBSCRIBER BASED QUESTION AND ANSWER FORUM THAT IS AVAILABLE THROUGH EMAIL. |
| MEDICAID INTEGRITY PROGRAM (MIP) | FRAUD AND ABUSE DETECTION PROGRAM CREATED BY THE DEFICIT REDUCTION ACT OF 2005. |
| MEDICAL REVIEW (MR) | DEFINED BY CMS AS A REVIEW OF CLAIMS TO DETERMINE WHETHER SERVICES PROVIDED ARE MEDICALLY REASONABLE AND NECESSARY, AS WELL AS TO FOLLOW UP ON THE EFFECTIVENESS OF PREVIOUS CORRECTIVE ACTIONS. |
| MEDICARE ADMINISTRATIVE CONTRACTOR (MAC) | AN ORGANIZATION THAT CONTRACTS WITH CMS TO PROCESS CLAIMS AND PERFORM PROGRAM INTEGRITY TASKS FOR MEDICARE PART A AND B AND DMEPOS; MAKES PROGRAM COVERAGE DECISIONS AND PUBLISHES A NEWSLETTER WHICH IS SENT TO PROVIDERS WHO RECEIVE MEDICARE REIMBURSEMENT. |
| MEDICARE INTEGRITY PROGRAM (MIP) | AUTHORIZES CMS TO ENTER INTO CONTRACTS WITH ENTITIES TO PERFORM COST REPORT AUDITING, MEDICAAL REVIEW, ANTI-FRAUD ACTIVITIES AND THE MEDICARE SECONDARY PAYER (MSP) PROGRAM. |
| MEDICARE SHARED SAVINGS PROGRAM | MANDATED BY THE PATIENT PROTECTION AND PORTABLE CARE ACT (PPACA) CMS ESTABLISHED THESE TO FACILITATE COORDINATION AND COOPERATION AMONG PROVIDERS TO IMPROVE QUALITY OF CARE FOR MEDICARE FEE-FOR-SERVICE BENEFICIARIES AND TO REDUCE THE UNNECESSARY COST. |
| MESSAGE DIGEST | REPRESENTATION OF TEXT AS A SINGLE STRING OF DIGITS, WHICH WAS CREATED USING A FORMULA; FOR THE PURPOSE OF ELECTRONIC SIGNATURES, THE MESSAGE DIGEST IS ENCRYPTED AND APPENDED TO AN ELECTRONIC DOCUMENT. |
| NATIONAL DRUG CODE (NDC) | MAINTAINED BY THE FOOD AND DRUG ADMINISTRATION (FDA); IDENTIFIES PRESCRIPTION DRUGS AND SOME OVER-THE-COUNTER PRODUCTS. |
| NATIONAL HEALTH PLANID (PLANID) | UNIQUE IDENTIFIER, PREVIOUSLY CALLED PAYERID, THAT WILL BE ASSIGNED TO THIRD-PARTY PAYERS AND IS EXPECTED TO HAVE 10 NUMERIC POSITIONS, INCLUDING A CHECK DIGITY IN THE 10TH POSITION. |
| NATIONAL INDIVIDUAL IDENTIFIER | UNIQUE INDENTIFIER TO BE ASSIGNED TO PATIENTS. |
| NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM (NPPES) | DEVELOPED BY CMS TO ASSIGN UNIQUE IDENTIFIERS TO HEALTHCARE PROVIDERS (NPI)AND HEALTH PLANS (PLANID) |
| NATIONAL PROVIDER IDENTIFIER (NPI) | UNIQUE IDENTIFIER TO BE ASSIGNED TO HEALTHCARE PROVIDERS AS AN 8 OR POSSIBLY 10 CHARACTOR ALPHANUMERIC IDENTIFIER, INCLUDING A CHECK DIGIT IN THE LAST POSITION. |
| NATIONAL STANDARD EMPLOYER INDENTIFICATION NUMBER (EIN) | UNIQUE IDENTIFIER ASSIGNED TO EMPLOYERS WHO NEED TO BE IDENTIFIED IN HEALTHCARE TRANSACTIONS. |
| NATIONAL STANDARD FORMAT (NSF) | FLAT-FILE FORMAT USED TO BILL PHYSICIAN AND NONINSTITUTIONAL SERVICES, SUCH AS SERVICES REPORTED BY A GENERAL PRACTITIONER ON A CMS-1500 CLAIM. |
| OVERPAYMENT | FUNDS A PROVIDER HAS RECEIVED IN EXCESS OF AMOUNTS DUE AND PAYABLE UNDER MEDICARE AND MEDICAID STATUTES AND REGULATIONS. |
| PART A/B MEDICARE ADMINISTRATIVE CONTRACTOR (A/B MAC) | AN ORGANIZATION THAT CONTRACTS WITH CMS TO PROCESS CLAIMS AND PERFORM PROGRAM INTEGRITY TASKS FOR MEDICARE PART A AND B AND DMEPOS; MAKES PROGRAM COVERAGE DECISIONS AND PUBLISHES A NEWSLETTER WHICH IS SENT TO PROVIDERS WHO RECEIVE MEDICARE REIMBURSEMENT. |
| PATIENT SAFETY AND QUALITY IMPROVEMENT ACT PART I | AMENDS TITLE IX OF THE PUBLIC HEALTH SEVICE ACT TO PROVIDE FOR IMPROVED PATIENT SAFETY BY ENCOURAGING VOLUNTARY AND CONFIDENTIAL REPORTING OF EVENTS THAT ADVERSELY AFFECT PATIENTS; CREATES PATIENT SAFETY ORGANIZATIONS (PSO) TO COLLECT; |
| PATIENT SAFETY AND QUALITY IMPROVEMENT ACT PART II | AGGREGATE, AND ANALYZE CONFIDENTIAL INFORMATION REPORTED BY HEALTHCARE PROVIDERS AND DESIGNATES INFORMATION REPORTED TO PSOs AS PRIVILEDGED AND NOT SUBJECT TO DISCLOSURE UNLESS A COURT DETERMINES OTHERWISE. |
| PAYMENT ERROR PREVENTION PROGRAM (PEPP) | REQUIRED FACILITIES TO IDENTIFY AND REDUCE IMPROPER MEDICARE PAYMENTS AND SPECIFICALLY, THE MEDICARE PAYMENT ERROR RATE. THE HOSPITAL PAYMENT MONITORING PROGRAM (HPMP) REPLACED PEPP IN 2002 |
| PAYMENT ERROR RATE | NUMBER OF DOLLARS PAID IN ERROR OUT OF TOTAL DOLLARS PAID FOR INPATIENT PROSPECTIVE PAYMENT SYSTEM SERVICES. |
| PAYMENT ERROR RATE MEASUREMENT PROGRAM (PERM) | MEASURES IMPROPER PAYMENTS IN THE MEDICAID PROGRAM AND THE STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) |
| PHYSICIAN QUALITY REPORTING SYSTEM | THE TAX RELIEF AND HEALTH CARE ACT OF 2006 (TRHCA) THAT ESTABLISHED FINANCIAL INCENTIVES FOR ELIGIBLE PROFESSIONALS WHO PARTICIPATE IN A VOLUNTARY QUALITY REPORTING PROGRAM; PREVIOUSLY CALLED PHYSICIAN QUALITY INITIATIVE (PQRI) SYSTEM. |
| PHYSICIAN SELF-REFERRAL LAW (SAME AS STARK I) PART I | RESPONDED TO CONCERNS ABOUT PHYSICIANS' CONFLICTS OF INTEREST WHEN REFERRING MEDICARE PATIENTS FOR A VARIETY OF SERVICES; PROHIBITS PHYSICIANS FROM REFERRING MEDICARE PATIENTS TO CLINICAL LABORATORY SERVICES IN WHICH THE PHYSICIAN OR A MEMBER OF THE |
| PHYSICIAN SELF-REFERRAL LAW (SAME AS STARK I) PART II | PHYSICIAN'S FAMILY HAS A FINANCIAL OWNERSHIP/INVESTMENT INTEREST AND/OR COMPENSATION ARRANGEMENT; ALSO CALLED PHYSICIAN SELF-REFERRAL LAW. |
| PHYSICIANS AT TEACHING HOSPITALS (PATH) | HHS STARTEDD AUDITS IN 1995 TO EXAMINE BILLING PRACTICES OF PHYSICIANS AT TEACHING HOSPITALS; IT FOCUSED ON: COMPLIANCE WITH MEDICARE RULE AFFECTING PAYMENT FOR SERVICES PROVIDED BY RESIDENTS & WHETHER THE LEVEL OF SERVICE WAS CODED AND BILLED PROPERLY. |
| PRECEDENT | STANDARD. |
| PRIVACY | RIGHT OF INDIVIDUALS TO KEEP THEIR INFORMATION FROM BEING DISCLOSED TO OTHERS. |
| PRIVACY ACT OF 1974 | FORBIDS THE MEDICARE REGIONAL PAYER FROM DISCLOSING THE STATUS OF ANY UNASSIGNED CLAIM BEYOND THE FOLLOWING: DATE THE CLAIM WAS RECEIVED BY THE PAYER; DATE THE CLAIM WAS PAID, DENIED, OR SUSPENDED; OR GENERAL REASON THE CLAIM WAS SUSPENDED. |
| PRIVACY RULE | HIPAA PROVISION THAT CREATES NATIONAL STANDARDS TO PROTECT INDIVIDUALS' MEDICAL RECORDS AND OTHER PERSONAL HEALTH INFORMATION. |
| PRIVILEGED COMMUNICATION | PRIVATE INFORMATION SHARED BETWEEN A PATIENT AND HEALTHCARE PROVIDER; DISCLOSURE MUST BE IN ACCORDANCE WITH HIPAA AND/OR INDIVIDUAL STATE PROVISIONS REGARDING THE PRIVACY AND SECURITY OF PROTECTED HEALTH INFORMATION (PHI). |
| PROGRAM FOR EVALUATING PAYMENT PATTERNS ELECTRONIC REPORT (PEPPER) | CONTAINS HOSPITAL-SPECIFIC ADMINISTRATIVE CLAIMS DATA FOR A NUMBER OF CMS-IDENTIFIED PROBLEM AREAS (E.G., SPECIFIC DRGs, TYPES OF DISCHARGES); A HOSPITAL USES PEPPER DATA TO COMPARE ITS PERFORMANCE WITH THAT OF OTHER HOSPITALS. |
| PROGRAM SAFEGUARD CONTRACTS (PSCs) | RESPONSIBLE FOR FRAUD AND ABUSE DETECTION FROM CARRIERS AND FISCAL INTERMEDIARIES (FIs). IN 2009, PSCs WERE REPLACED BY THE ZONE PROGRAM INTEGRITY CONTRACTOR (ZPIC). |
| PROGRAM TRANSMITTAL | DOCUMENT PUBLISHED BY MEDICARE CONTAIN NEW/CHANGED POLICIES OR PROCEDURES THAT ARE INCORPORATED INTO A CMS PROGRAM MANUAL; SUMMARIZES NEW/CHANGED MATERIAL, SUBSEQUENT PAGES PROVIDE DETAILS. THEY ARE TO BE SENT TO EACH MEDICARE ADMINISTRATIVE CONTRACTOR. |
| PROTECTED HEALTH INFORMATION (PHI) | INFORMATION THAT IS IDENTIFIABLE TO AN INDIVIDUAL (OR INDIVIDUAL IDENTIFIERS) SUCH AS NAME, ADDRESS, TELEPHONE NUMBERS, DATE OF BIRTH, MEDICAID ID NUMBER, MEDICAL RECORD NUMBER, SOCIAL SECURITY NUMBER (SSN), AND NAME OF EMPLOYER. |
| QUI TAM PART I | ABBREVIATION FOR THE LATIN PHRASE - QUI TAM PRO DOMINO REGE QUAM PRO SIC IPSO IN HOC PARTE SEQUITUR. MEANS "WHO AS WELL FOR THE KING AS FOR HIMSELF SUES I THIS MATTER" |
| QUI TAM PART II | IT'S A PROVISION OF THE FALSE CLAIMS ACT THAT ALLOWS A PRIVATE CITIZEN TO FILE A LAWSUIT IN THE NAME OF THE U.S. GOVERNMENT, CHARGING FRAUD BY GOVERNMENT CONTRACTORS AND OTHER ENTITIES. |
| RECORD RETENTION | STORAGE OF A DOCUMENTATION FOR AN ESTABLISHED PERIOD OF TIME, USUALLY MANDATED BY FEDERAL AND/OR STATE LAW; ITS PURPOSE IS TO ENSURE THE AVAILABILITY OF RECORDS FOR USE BY GOVERNMENT AGENCIES AND OTHER THIRD PARTIES. |
| RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM | MANDATED BY THE MEDICARE PRESCRIPTION DRUG, IMPROVEMENT AND MODERNIZATION ACT OF 2003 (MMA) TO FIND AND CORRECT IMPROPER MEDICARE PAYMENTS PAID TO HEALTHCARE PROVIDERS PARTICIPATING IN FEE-FOR-SERVICE MEDICARE. |
| REGULATIONS | GUIDELINES WRITTEN BY ADMINISTRATIVE AGENCIES (E.G., CMS). |
| RELEASE OF INFORMATION (ROI) PART I | ROI BY A COVERED ENTITY ABOUT PROTECTED HEALTH INFORMATION REQUIRES THE PATIENT TO SIGN AN AUTHORIZATION TO RELEASE INFORMATION, WHICH IS REVIEWED FOR AUTHENTICITY AND PROCESSED WITHIN AN HIPAA MANDATED 60-DAY LIMIT. |
| RELEASE OF INFORMATION (ROI) PART II | REQUESTS FOR ROI INCLUDE THOSE FROM PATIENTS, PHYSICIANS AND OTHER HEALTHCARE PROVIDERS; THIRD-PARTY PAYERS; SOCIAL SECURITY DISABILITY ATTORNEYS AND SO ON. |
| RELEASE OF INFORMATION LOG | USED TO DOCUMENT PATIENT INFORMATION RELEASED TO AUTHORIZED REQUESTORS; DATA IS ENTERED MANUALLY (E.G., THREE-RING BINDER) OR USING ROI TRACKING SOFTWARE. |
| SECURITY | SAFEKEEPING OF PATIENT INFOMATION BY CONTROLLING ACCESS TO HARD COPY AND COMPUTERIZED RECORDS. PROTECTION INFORMATION FROM ALTERATION, DESTRUCTION OR LOSS; PROVIDE EMPLOYEE TRAINING IN CONFIDENTIALITY AND SIGNATURE OF STATEMENT THAT DETAILS CONSEQUENCES. |
| SECURITY RULE | HIPAA STANDARDS AND SAFEGUARDS THAT PROTECT HEALTH INFORMATION COLLECTED, MAINTAINED, USED OR TRANSMITTED ELECTRONICALLY; COVERED ENTITIES AFFECTED BY THIS RULE INCLUDE HEALTH PLANS, HEALTHCARE CLEARINGHOUSES AND CERTAIN HEALTHCARE PROVIDERS. |
| STARK I (SAME AS PHYSICIAN SELF-REFERRAL LAW) PART I | RESPONDED TO CONCERNS ABOUT PHYSICIANS CONFLICTS OF INTEREST WHEN REFERRING MEDICARE PATIENTS FOR A VARIETY OF SERVICES; PROHIBITS TO CLINICAL LABORATORY SERVICES IN WHICH THE PHYSICIAN OR A MEMBER OF THE |
| STARK I (SAME AS PHYSICIAN SELF-REFERRAL LAW) PART II | PHYSICIAN'S FAMILY HAS A FINANCIAL OWNERSHIP/INVESTMENT INTEREST AND/OR COMPENSATION ARRANGEMENT; ALSO CALLED PHYSICIAN SELF-REFERRAL LAW. |
| STATUTE (SAME AS STATUTORY LAW) | ALSO CALLED STATUTORY LAW; LAWS PASSED BY LEGISLATIVE BODIES (FEDERAL CONGRESS AND STATE LEGISLATURES). |
| STATUTORY LAW (SAME AS STATUTE) | ALSO CALLED STATUTE; LAWS PASSED BY LEGISLATIVE BODIES (FEDERAL CONGRESS AND STATE LEGISLATURES). |
| SUBPOENA | AN ORDER OF THE COURT THAT REQUIRES A WITNESS TO APPEAR AT A PARTICULAR TIME AND PLACE TO TESTIFY. |
| SUBPOENA DUCES TECUM | REQUIRES DOCUMENTS (LIKE PATIENT RECORDS) TO BE PRODUCED. |
| TAX RELIEF AND HEALTH CARE ACT OF 2006 (TRHCA) | CREATED PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI) SYSTEM THAT ESTABLISHES A FINANCIAL INCENTIVE FOR ELIGIBLE PROFESSIONALS WHO PARTICIPATE IN A VOLUNTARY QUALITY REPORTING PROGRAM. |
| UB-04 | INSURANCE CLAIM OR FLAT FILE USED TO BILL INSTITUTIONAL SERVICES, SUCH AS SERVICES PERFORMED AT HOSPITALS |
| UNIQUE BIT STRING | COMPUTER CODE THAT CREATES AN ELECTRONIC SIGNATURE MESSAGE DIGEST THAT IS ENCRYPTED AND APPENDED TO AN ELECTRONIC DOCUMENT. |
| UPCODING | ASSIGNMENT OF AN ICD-9-CM DIAGNOSIS CODE THAT DOES NOT MATCH PATIENT RECORD; DOCUMENTATION FOR THE PURPOSE OF ILLEGALLY INCREASING REIMBURSEMENT. |
| WHISTLEBLOWER | INDIVIDUAL WHO MAKES SPECIFIED DISCLOSURES RELATING TO THE USE OF PUBLIC FUNDS, SUCH AS MEDICARE PAYMENTS. ARRA LEGISLATION PROHIBITS RETALIATION AGAINST THOSE WHO DISCLOSE INFORMATION THAT THEY BELIEVE IS EVIDENCE OF GROSS MISMANAGEMENT OF A CONTRACT. |
| ZONE PROGRAM INTEGRITY CONTRACTOR (ZPIC) | IMPLEMENTED IN 2009 BY CMS TO REVIEW BILLING TRENDS AND PATTERNS, FOCUSING ON PROVIDERS WHOSE BILLINGS FOR MEDICARE SERVICES ARE HIGHER THAN THE MAJORITY OF PROVIDERS IN THE COMMUNITY. |
Created by:
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