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M.I. Glossary

Medical Insurance An Integrated Approach

QuestionAnswer
abuse Actions that improperly use another person's resources.
accept assignment (acceptance of assignment) A participating physician's agreement to accept the allowed charge as payment in full.
access The ability or means necessary to read, write, modify, or communicate information or otherwise use a system resource.
accounts receivable (A/R) Monies owed to a medical practice by its patients and third-party payers.
Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N) The ANSI-accredited standards development organization that maintains the administrative and financial electronic transactions standards adopted under HIPAA.
Acknowledgment of Receipt of Notice of Privacy Practices Form accompanying a covered entity's Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment.
acute Describes an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.
addenda Updates to the ICD-9-CM diagnostic coding system.
Additional Documentation Request Carrier request for information during a Medicare Medical Review.
add-on code Procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+).
adjudication The process followed by health plans to examine claims and determine benefits.
adjustment An amount (positive or negative) entered in a patient billing program to change a patient's account balance.
administrative code set Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.
administrative services only (ASO) Contract under which a third-party adminstrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.
Admission of Liability Carrier's determination that an employer is responsible for an employee's claim under workers' compensation.
admitting diagnosis (ADX) The patient's condition determined by a physician at admission to an inpatient facility.
advance beneficiary notice of non-coverage (ABN) Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
adverse effect Condition caused by a drug that has been used correctly.
advisory opinion An opinion issued by CMS or OIG that becomes legal advice for the requesting party; a requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for others in similar matters.
administrative services only (ASO) Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.
aging Classification of accounts receivable by the length of time an account is due.
allowed charge The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Alphabetic Index The section of ICD-9-CM in which diseases and injuries with corresponding diagnosis codes are presented in alphabetical order.
ambulatory care Outpatient care.
ambulatory patient classification (APC). A Medicare payment classification for outpatient services.
ambulatory surgical center (ASC) A clinic that provides outpatient surgery.
American Academy of Professional Coders (AAPC) National association that fosters the establishment and maintenance of professional, ethical, educational, and certification standards for medical coding.
American Association of Medical Assistants National association that fosters the profession of medical assisting.
American Association for Medical Transcription National association fostering the profession of medical transcription.
American Health Information Management Association (AHIMA) National association of health information management professional that promotes valid, accessible, yet confidential health information and advocates quality health care.
American Medical Association (AMA) Member organization for physicians that aims to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession.
American National Standards Institute (ANSI) Organization that sets standards for electronic data interchange on a national level.
American Recovery and Reinvestment Act (ARRA) of 2009 Federal law containing additional provisions concerning the standards for the electronic transmission of health care data, also known as the Stimulus Package.
ancillary services Supplemental medical services such as diagnostic services and occupational therapy that support the diagnosis and treatment of patients' conditions.
appeal A request sent to a payer for reconsideration of a claim adjudication.
appellant One who appeals a claim decision.
assignment of benefits Authorization by a policyholder that allows a health plan to pay benefits directly to a provider.
assumption coding Reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition.
at-home recovery care Assistance with the activities of daily living provided for a patient in the home.
attending physician The clinician primarily responsible for the care of the patient from the beginning of a hospitalization.
audit Methodical review; in medical insurance, a formal examination of a physician's accounting or patient medical records.
authorization (1) Document signed by a patient to permit release of particular medical information under the stated specific conditions. (2) A health plan's system of approving payment of benefits for services that satisfy the plan's requirement for coverage.
auto-posting Software feature that enables automatic entry of payments on a remittance advice to credit an individual's account.
bad debt An account deemed uncollectible.
balance billing Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured.
bankruptcy Legal declaration that a person is unable to pay his or her debt.
benefits The amount of money a health plan pays for services covered in an insurance policy.
billing provider The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to-provider who receives payment.
billing service Company that provides billing and claim processing services.
birthday rule The guideline that determines which of two parents with medical coverage has the primary insurance for a child, the parent whose day of birth is earlier in the calendar year is considered primary.
BlueCard A Blue Cross and Blue Shield program that provides benefits for plan subscribers who are away from their local areas.
Blue Cross A primarily nonprofit corporation that offers prepaid medical benefits for hospital services and some outpatient, home care, and other institutional services.
Blue Cross and Blue Shield Association (BCBS) The national licensing agency of Blue Cross and Blue Shield.
Blue Shield A primarily nonprofit corporation that offers prepaid medical benefits for physician, dental, and vision services and other outpatient care.
breach An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI and also that could pose significant risk of financial, reputational, or other harm to the affected person.
breach notification The document notifying an individual of a breach.
bundling A single procedure code that covers a group of related procedures.
business associate (BA) A person or organization that performs a function or activity for a covered entity but is not part of its workforce.
capitation Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
capitation rate (cap rate) The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
carrier Health plan; also known as insurance company, payer, or third-party payer.
carrier block Date entry area located in the upper right of the CMS-1500 that allows for a four-line address for the payer.
carve out A part of a standard health plan that is changed under a negotiated employer-sponsored plan; also refers to subcontracting of coverage by a health plan.
case mix index A measure of the clinical severity or resource requirements of the patients in a particular hospital or treated by a particular clinician during a specific time period.
cash flow The inflow of payments from patients and payers to a medical practice and the outflow from thepractice of payments to suppliers and staff; based on the actual movement of money rather than amounts that are receivable or payable.
catastrophic cap The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share.
catchment area A geographic area usually within approximately forty miles of military inpatient treatment facilities, under TRICARE,the facility in a patient's area must issue a nonavailability statement before the patient can be treated at a nonmilitary facility.
categorically needy A person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF).
category In ICD-9-CM, a three-digit code used to classify a particular disease or injury.
Category I codes Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, and Medicine).
Category II codes Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use.
Category III codes Temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available.
CCI column 1/column 2 code pair edit A Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code.
CCI modifier indicator A number that shows whether the use of a modifier can bypass a CCI edit.
CCI mutually exclusive code (MEC) edit Under the CCI edits, both services represented by MEC codes could not have reasonably been done during a single patient encounter, so they will not both be paid by Medicare; only the lower-paid code is reimbursed.
Centers for Medicare and Medicaid Services (CMS) Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs.
certificate Term for a Blue Cross and Blue Shield medical insurance policy.
Certificate of Medical Necessity (CMN) A document used by the four DME MACs to assist them in gathering information before the supplier's claim is paid.
certification The recognition of a person demonstrating a superior level of skill on a national test by an official organization.
Certification Commission for Healthcare Information Technology (CCHIT) Voluntary, private-sector organization that certifies EHR products.
certification number Number returned electronically by a health plan when approving a referral authorization request.
CHAMPUS Now the TRICARE program; formerly the Civilian Health and Medical Program of the Uniformed Services that serves spouses & children of active-duty service members, military retirees & their families, some former spouses, & survivors of deceased military.
CHAMPVA The Civilian Health & Medical Program of Dept. of Veteran Affairs that shares health care costs for families of veterans with 100% service-connected disabilities & the surviving spouses & children of veterans who die from service-connected disabilities.
charge-based fee structure Fees based on the amounts typically charged for similar services.
charge capture Office procedures that ensure that billable services are recorded and reported for payment.
charge master A hospital's list of the codes and charges for its services.
chart number A unique number that identifies a patient.
chief complaint (CC) A patient's description of the symptoms or other reasons for seeking medical care from a provider.
chronic An illness or condition with a long duration.
Civilian Health and Medical Program of the Department of Veterans Affairs CHAMPVA
Civilian Health and Medical Program of the Uniformed Services CHAMPUS
claim adjustment group codes (CAGC) Codes used by a payer on an RA/EOB to indicate the general type of reason code for an adjustment.
claim adjustment reason code (CARC) Code used by a payer on a RA/EOB to explain why a payment does not match the amount billed.
claimant Person or entity exercising the right to receive benefits.
claim attachment Documentation that a provider sends to a payer in support of health care claim.
claim control number Unique number assigned to a health care claim by the sender.
claim filing indicator code Administrative code used to identify the type of health plan.
claim frequency code (claim submission reason code) Administrative code that identifies the claim as original, replacement, or void/cancel action.
claim scrubber Software that checks claims to permit error correction for clean claims.
claim status category codes Codes used by payers on a HIPAA 277 to report the status group for a claim,such as received or pending.
claim status codes Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry.
claim turnaround time The time period in which a health plan is obligated to process a claim.
clean claim A claim that is accepted by a health plan for adjudication.
clearinghouse A company (billing service, repricing company, or network) that transmits transaction data to health plans.
Clinical Laboratory Improvement Amendments (CLIA) Federal law establishing standards for laboratory testing performed in hospital-based facilities, physicians' office laboratories,and other locations administered by CMS.
CMS Centers for Medicare and Medicaid Services
CMS-1450 Paper claim for hospital services also known as the UB-92.
CMS-1500 Paper claim for physician services
CMS-1500 (08/05) Current paper claim approved by the NUCC (National Uniform Claims Committee).
CMS HCPCS Workgroup Federal government committee that maintains the Level II HCPCS code set.
code edits Computerized screening system used to identify improperly or incorrectly reported codes.
code linkage The connection between a service and a patient's condition or illness; establishes the medical necessity of the procedure.
code set Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (non-medical) code sets, such as taxonomy codes and Zip codes, are also used in HIPAA transactions.
coding The process of assigning numerical codes to diagnoses and procedures/services.
coexisting condition Additional illness that either has an effect on the patient's primary illness or is also treated during the encounter.
coinsurance The portion of charges that an insured person must pay for health care services after payment of the deductible amount, usually stated as a percentage.
collection agency Outside firm hired by a practice or facility to collect overdue accounts from patients.
collections The process of following up on overdue accounts.
collections specialist Administrative staff member with training in proper collections techniques.
combination code A single code that classifies both the etiology and the manifestation of an illness or injury.
Common Working File (CWF) Medicare's master patient/procedural database.
comorbidity Admitted patient's coexisting condition that affects the length of the hospital stay or the course of treatment.
compliance Actions that satisfy official guidelines and requirements.
compliance plan A medical practice's written plan for the following: appt. of compliance officer & committee; a code of conduct for physicians' business arrangements & employees' compliance; training plans' rules for prompt identification & refunding of over-payments.
complication Condition an admitted patient develops after surgery or treatment that affects the length of hospital stay or the course of further treatment.
computer-assisted coding (CAC) A software program that assists providers and medical coders in assigning codes based on the documentation of a visit.
concurrent care Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service.
condition code Two-digit numeric or alphanumeric
conditions of participation (Medicare) (COP) Regulations concerning provider participation in the Medicare program.
conscious sedation Moderate, drug-induced depression of consciousness.
Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for eighteen months after termination.
consultation Service performed by a physician to advise a requesting physician about a patient's condition and care; the consultant does not assume responsibility for the patient's care and must send a written report back to the requestor.
consumer-driven health plan (CDHP) Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
contract An enforceable voluntary agreement in which specific promises are made by one party in exchange for some consideration by the other party.
convention Typographic techniques or standard practices that provide visual guidelines for understanding printed material.
conversion factor Dollar amount used to multiply a relative value unit to arrive at a charge.
coordination of benefits (COB) A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
copayment An amount that a health requires a beneficiary to pay at the time of service for each health care encounter.
corporate integrity agreement A compliance action under which a provider's Medicare billing is monitored by the Office of the Inspector General.
Correct Coding Initiative (CCI) Computerized Medicare system to prevent overpayment for procedures.
Correct Coding Initiative edits Pairs of CPT or HCPCS Level II codes that are not separately payable by Medicare except under certain circumstances, the edits apply to services by the same provider for the same beneficiary on the same date of service.
cost share Coinsurance for a TRICARE or CHAMPVA beneficiary.
Coverage Issues Manual (CIM) Information about Medicare-qualified clinical trials, treaments, therapeutic interventions, diagnostic testing,durable medical equipment, therapies, and services referenced in the HCPCS code manual.
covered entity (CE) Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with a HIPAA transaction; does not specif. incl: workers' comp, property & casualty programs, or disability insurance programs.
covered services Medical procedures and treatments that are included as benefits under an insured's health plan.
counseling Physician's discussion with a patient and/or family about diagnostic results, prognosis, treatment options and/or instructions.
CPT Current Procedural Terminology, a publication of the American Medical Association.
credentialing Periodic verification a provider or facility meets professional standards of certifying organization; physician credentialing involves screening & eval. qualifications & credentials, incl. licensure, required educ., relevant exp. & current competence.
creditable coverage History of health insurance coverage for calculation of COBRA benefits.
credit bureaus Organizations that supply information about consumers' credit history and relative standing.
credit reporting Analysis of a person's credit standing during the collections process.
crossover claim Claim for a Medicare or Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer.
cross-reference Directions in printed material that tell a reader where to look for additional information.
crosswalk A comparison or map of the codes for the same or similar classifications under two coding systems; it serves as a guide for selecting the closest match.
Current Procedural Terminology (CPT) Publication of the American Medical Association containing the HIPAA-mandated standardized classification system for reporting medical procedures and services performed by physicians.
cycle billing Type of billing in which patients with current balances are divided into groups to even out statement printing and mailing throughout a month, rather than mailing all statement once a month.
Created by: Laura Duncan