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Accepting Assignment When a provider agrees to accept the allowable charges as the full fee and cannot charge the patient the difference between the insurance payment and the provider’s normal fee.
Access The patient's ability to obtain medical care. Ease of access is determined by components as the availability of medical services, their acceptability to the patient, location of health care facilities, transportation, hours of operation and cost of care.
Account Number A number assigned to each account. This number is used to identify the account and all charges and payments received.
Acute Care Medical attention given to patients with conditions of sudden onset that demand urgent attention or care of limited duration when the patient’s health and wellness would deteriorate without treatment.
Acute Care The care is generally short-term rather than long-term or chronic care.
Acute Inpatient Care A level of health care delivered to patients experiencing acute illness or trauma. Generally short-term < 30days
Add-Ons Patients who are scheduled for services less than 24 hours in advance of the actual service time.
Adjustor Insurance company representative.
Administrative Costs Costs associated with creating and submitting a bill for services, which could include: registration, utilization review, coding, billing, and collection expenses.
Admission Authorization The process of third party payor notification of urgent/emergent inpatient admission within specified time as determined by payors (usually 24-48 hours or next business day).
Admission Date The first date the patient entered the hospital for a specific visit
Admitting Diagnosis Word, phrase, or International Classification of Disease (ICD9) code used by the admitting physician to identify a condition or disease from which a patient suffers and for which the patient needs or seeks medical care.
Admitting Physician The physician who writes the order for the patient to be admitted to the hospital. This physician must have admitting privileges at the facility providing the healthcare services.
Advance Beneficiary Notice (ABN) Notice that a care provider should give a Medicare beneficiary to sign if the services being provided may not be considered medically necessary and Medicare may not pay for them.
Advance Directive Written instruction relating to the provision of healthcare when a patient is incapacitated. Appointing someone to make medical decisions, expressing the patients wishes (organ donation) whether or not life-sustaining treatments
Adverse Selection Among applicants for a given group or individual program, the tendency for those with an impaired health status, or who are prone to higher than average utilization of benefits to be enrolled in disproportionate numbers and lower deductible plans.
Alias Name by which the patient is also “known as”, or formerly known as.
All Patient Diagnosis Related Groups Assignment of Benefits (APDRG) hospital claims reimbursement system currently utilized by the federal government Medicaid program and the states of New York and New Jersey. APDRGs were designed to describe the complete cross section of patients seen in acute care hospitals
All Patient Diagnosis Related Groups Assignment of Benefits (APDRG) Approximately 639 APDRGs are defined according to the principal diagnosis, secondary diagnoses, procedures, age, birth weight, sex, discharge status.
Ambulatory Care Patient Patient receives medical or surgical care in an outpatient setting that involves a broader, less specialized range of care.
Ambulatory Care Patient _________ are generally able to walk and are not confined to a bed. In a hospital setting, ambulatory care generally refers to healthcare services provided on an outpatient basis. Ambulatory Payment Classification (APC) A system of
Ambulatory Payment Classification (APC) A system of averaging and bundling using Current Procedural Terminology (CPT) procedure codes, Healthcare Common Procedure Coding System (HCPCS) Level II, and revenue codes submitted for payment.
APC The ___ system utilizes groups of CPT codes based on clinical and resource similarity and establishes payment rates for each APC grouping.
650 The ______ + APCs are divided by significant procedures, medical services, ancillary services and partial hospitalization services.
APC System similar to Diagnosis Related Group’s (DRG) to be used for outpatients. Includes 346 APCs broken into categories of Medical, Diagnostic, Surgical, and Radiology and include Emergency Department and partial hospitalization services.
Ambulatory Surgical Center A freestanding facility, other than a physician’s office, where surgical, diagnostic, and therapeutic services are provided on an outpatient ambulatory basis.
Ancillary Services A unit of the hospital, other than a nursing unit, provides medical services such as diagnostic testing, therapeutic procedures, or dispenses medical products,meds or medical/surgical supplies. Laboratory, Medical Imaging, Physical Therapy, Pharmacy
Ancillary _________ is used to describe diagnostic or therapeutic services, such as laboratory, radiology, pharmacy, or physical therapy, performed by departments that do not have inpatient beds.
Annual Maximum Benefit Amount Deductible The maximum dollar amount set by a Managed Care Organization (MCO) that limits the total amount the plan must pay for all health care services provided to a subscriber in a year.
Deductible A _______ is the set amount, per benefit year or period, the third party payor designates as the patient/guarantor’s responsibility. Usually the deductible must be paid before benefits will be paid by the payor.
Appeal special kind of complaint made when a beneficiary or provider disagrees with decisions about health care services – typically related to payment issues. There is usually a special process used to appeal payor decisions.
Appropriate Care A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
Assignment of Benefits Written authorization from the policyholder for their insurance company to pay benefits directly to the care provider. Normally acquired at the time of admission or registration.
Attending Physician The physician who writes outpatient orders for tests, or supervises the patient’s care during an inpatient stay.
Authorization Approval obtained from an insurance carrier for a service that represents an agreement for payment.
Authorization to Release Medical Information The form authorizing to release information from the medical records to doctors, hospitals, insurance, other agencies, etc.
Average Daily Census The average number of inpatients maintained in the hospital for each day for a specific period of time.
Average Length of Stay The average number of days of service rendered to each patient during a specific time period.
Bad Debt An accounts receivable that is regarded as uncollectible and is charged as a credit loss even though the patient has the ability to pay.
Balance Billing The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made.
Batch Processing Information technology term referring to grouping similar input items and then processing them together during a single machine run.
Behavioral Health Assessment and treatment of mental and/or psychoactive substance abuse disorders.
Beneficiary Person designated to receive the proceeds of an insurance policy; the insured under a health insurance policy. Also referred to as eligible; enrollee; or member.
Benefit Period The number of days that Medicare covers care in hospitals and skilled nursing facilities are measured in benefit periods.
Benefit Period A ______ begins on the first day of services of a patient in a hospital or skilled nursing facility and ends 60 days after discharge from the hospital or skilled nursing facility if 60 days has not been interrupted by skilled care in any other facility.
Benefit Period, Inpatient Deductible There is no limit to the number of ______, The beneficiary must pay the _________ for each benefit period.
Benefit Verification The process of confirming benefits for services.
Birthday Rule A rule used to determine whose insurance is primary for a child covered under both parents' insurance.
Birthing Center A facility, other than a hospital’s maternity facility or a physician’s office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care for newborn infants.
Capitation A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per member/per month basis regardless of the services that are actually rendered.
Carrier A health insurance plan or another entity that processes and pays healthcare bills. May be called a third party payor, payor, carrier, or insurer. These terms are interchangeable. Carrier may also refer to an organization contracted with the CMS
Carve Out A decision to separately purchase a service, which is typically a part of an indemnity of a Health Maintenance Organization (HMO) plan.
Case Management process of identifying plan members with special health care needs, developing a health care strategy that meets those needs, and coordinating the care, with the ultimate goal of optimum health care outcome in an efficient and cost-effective manner.
Case Mix Index (CMI) determined by dividing the sum of all Diagnosis Related Group (DRG) relative weights for every DRG used by Medicare patients by the total number of Medicare inpatient cases for the hospital.
Census Verification The process of accurately accounting for all Admission- Discharge-Transfer (ADT) activity within or across entities.
(CDC) Major operating components of the Department of Health- mission is to promote health and quality of life by preventing and controlling disease, injury, and disability. and Human Services.
Charge Description Master is a master file in the computer System listing the services provided at the hospital that have an assigned charge.
Charity Care Financial Assistance program available to qualifying patients based on financial need.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Civilian Health and Medical Program of the Uniformed Services has been replaced by TRICARE.
Claim An itemized statement of health care services and their costs provided by a hospital, physician's office or other provider facility.
Claimant The person or entity submitting a claim.
Claims Administration Employees in the claims administration department who consider all the information pertinent to a claim and make decisions about the Managed Care Organization’s (MCO) payment of the claim.
Clinic A medical or surgical specialty unit of a hospital or hospitals’ free standing facility where a patient is seen on an ambulatory basis but remains the hospital’s responsibility for ongoing care and disposition.
Clinical Data Repository (CDR) The process of receiving, reviewing, adjudicating and processing claims.
Clinical Integration type of operational integration that enables patients to receive a variety of health services from the same organization or entity, which streamlines administrative processes and increases the potential for the delivery of high-quality health care.
Closed Access A provision which specifies that plan members must obtain medical services only from network providers through a primary care physician to receive benefits
CMS 1450 (UB-04) revised version of the UB-92, a federal directive requiring a hospital to follow specific billing procedures, itemizing all services included and billed for on each invoice
Co-insurance is another amount the third party payor can identify as the Patient/Guarantor’s responsibility/a percentage of the total billed amount
Co-insurance Days (CID) Coinsurance Days (CID) relate to Part A Medicare benefits. For each day of hospitalization over 60 days and up to the 90th day, a coinsurance payment of one-quarter of the inpatient deductible is due.
Collection Agency An outside vendor that collects payment on hospital accounts under contract with the hospital
Commercial Insurance This term is used to identify several types of insurance policies other than Managed Care
Common Working File (CWF) A national file system used to verify entitlement to and correct use of Medicare benefits and houses a record of all Medicare claims processed for a patient.
Co-morbidity A pre-existing condition that will, because of its presence with a specific principal diagnosis, cause an increased length of stay by at least one day.
Compliance The act of complying with a request, demand or regulation. Also known as Corporate Integrity. Conducting ourselves within the law in all our business practices.
Consent Voluntary permission or agreement.
Consent to Treat The patient’s or legally responsible party’s signed authorization for a hospital to provide medical care and treatment.
Conservator A conservator is a person, official, or institution designated by a court to take over and protect the financial or personal interests of an incompetent person
Consolidated Omnibus Budget Reconciliation Act (COBRA) The Consolidated Omnibus Budget Reconciliation Act of 1985 requires employers to permit employees or family members to continue their group health insurance coverage at their own expense.
Consulting Physician Physician, other than the admitting or attending physician, who has been asked to participate or provide counsel in a particular episode of care.
Consumer Driven Healthcare Refers to health plans in which individuals have a personal health savings account (HSA) or a health reimbursement account (HRA) from which they pay medical expenses
Continuum of Care The scope of healthcare services provided to an individual during a single episode of illness or for multiple conditions over a lifetime.
Contract A legal agreement between a payer and a subscribing group or individual which specifies rates, perf covenants, the relationship among the parties, schedule of benefits/other pertinent conditions. The contract usually is limited to a 12- month period.
Contract Provider Any hospital, skilled nursing facility, extended care facility, individual, organization, or agency licensed that has a contractual arrangement with an insurer for the provision of services under an insurance contract.
Contractual Allowance The amount that is not paid, due to a reimbursement agreement, is considered an adjustment or contractual allowance.
Coordination of Benefits (COB) The determination of primary, secondary, and tertiary payers must be completed either at registration or through the insurance verification process
Co-pay A co-pay fixed amount that the beneficiary pays for healthcare services,regardless of the actual charge.
Co-pay CMS 1500 CMS 1500 is the standard paper claim form used by physicians, non-institutional providers, suppliers to Medicare, and other clinicians.
Corporate Person Index (CPI) Corporate Person Index (CPI) or Master Patient Index (MPI) houses the Patient's medical record number and other key demographic information.
Courtesy Discharge When a patient is discharged from the hospital without settling his/her account and is to be billed later for the balance of the bill.
Covered Benefit A medically necessary service that is specifically provided for under the provisions of an Evidence of Coverage
Credentialing The process of reviewing a practitioner's training, experience, or demonstrated ability, for the purpose of determining if they meet the criteria to authorize the practitioner to practice medicine.
Critical Access Hospitals (CAH) Hospitals defined in rural areas designated for 25 inpatient beds which also serve as swing or skilled nursing beds.
Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS), or the Physicians Current Procedure Terminology, which is authored by the American Medical Association, or AMA.
Current Procedural Terminology, 4th Edition (CPT-4) Comprehensive listing of descriptive terms/ identifying codes for reporting medical services and procedures performed by physicians. Provides uniform language describe medical/surgical/Diagnostic services
Custodial Care Care that primarily supports and maintains the patient’s condition without active or aggressive medical treatment. The patient is mentally or physically disabled and/or the condition is expected to be prolonged.
Deductible fixed sum that a beneficiary must contribute towards the cost of their healthcare before insurance benefits begin
Default Term used when the system is programmed to place a predetermined value in a field that is left blank.
Dependent A person, other than the subscriber, who is covered under the insurance membership.
Deposit The amount of money a healthcare provider requires prior to rendering service.
Designated Code Set Medical Code set or an administrative code set that Health and Human Services (HHS) has designated for use in one of more of the HIPAA standards.
Designated Record Set For covered health care providers (under HIPAA), designated records sets include, at a minimum, the medical record and billing record about individuals maintained by or for the provider.
Diagnosis Related Group (DRG) System for classification for over 490 diagnoses based on patterns in resource consumption and length of stay. Used inmany prospective payment plans including Medicare.over 500 active DRGs within the inpatient prospective pricing methodology
Discharge Planning Medical personnel of the health plan work with the attending physician and hospital staff to assess alternatives to hospitalization, evaluate appropriate settings for care and arrange for discharge of a patient, including planning for subsequent care
Discounted Fee-For- Service An agreed upon rate for service between the provider and payor that is usually less than the provider's full fee. This may be a fixed amount per service, or a percentage discount.
Donor One from whom blood, tissue or an organ is taken for use in a transfusion or transplant.
Durable Medical Equipment (DME) Durable medical equipment typically withstands repeated use, improves function or retards further deterioration of a physical condition, and primarily provides a medical function. (Ex: Hospital bed; wheelchair)
Durable Power of Attorney for Healthcare legally assigned individual that is empowered to make medical treatment decisions on the patient’s behalf if the patient is incapacitated and cannot speak for him/herself. Also known as a Healthcare Agent or Proxy.
Effective Dates - Insurance The beginning and ending dates for which third-party financial responsibility is enforced. Any service dates before or after these dates will not be covered by a particular third-party.
Electronic Media Electronic media are the storage and transmission tools used to store and deliver information or data and utilizes electronics or electromechanical energy for the end user to access the content
Eligibility The act of confirming a person’s status with the employer or union is called an eligibility check. A person who is entitled to benefits according to an employer or union, and is currently covered by insurance.
Eligible Dependent A dependant of a covered employee who meets the requirements specified in the group contract to qualify for coverage and for whom premium payment is made
Eligible Expenses Reasonable and customary charges, or the agreed upon fee for health services and supplies covered under a health plan.
Email Email (or Electronic mail) is a telecommunications system that enables users to send messages prepared on a computer to another computer user.
Emancipation Legal term that means a child is no longer under the control of the parent.
Emergency Care Patient Patients examined on an unscheduled basis for immediate diagnosis and treatment in the emergency facilities of the hospital.
Emergency Medical Treatment and Active Labor Act (EMTALA) The Emergency Medical Treatment and Active Labor Act is a statute that governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable medical condition
Employer Group Health Plan (EGHP Health Insurance provided through an employer.
Encounter A face-to face meeting between a covered person and a health care provider where services are provided.
Enrolled Group Persons with the same employer or with membership in an organization in common, who are enrolled collectively in a health plan. Often, there are stipulations regarding the minimum size of the group and the minimum percentage of the group
Enrollee Any person eligible as either a subscriber or a dependent for service in accordance with a contract. Also refers to a member in a database. (Also beneficiary; individual; member)
Episode Also known as a “Visit,” an “Episode of Care,” or an encounter with the health system. The visit is initiated by a request for service.
Evidence of Coverage (EOC) An evidence of coverage (EOC) is an addendum of the group plan contract and constitutes only a summary of the terms and conditions of coverage.
Exclusions Specific conditions or circumstances listed in the contract or employee benefit plan for which the policy or plan will not provide benefit payments.
Exhaustion of Benefits The maximum contract amount payable by the insurance carrier for services. Many payors have a calendar year and a lifetime maximum limit on benefits they will pay for
Explanation of Benefits (EOB) The statement sent to a covered person by a health plan, listing services provided, benefits paid on the claim, deductible and/or co-payment amounts, and any remaining balance due.
Fee Schedule A listing of accepted fees or established allowances for specified medical procedures.
Fee-for-service The traditional healthcare payment system, under which physicians and other providers receive a payment for each unit of service provided.
Financial Class A code that identifies the primary insurance for an account. Financial class codes are related to insurance plan codes.
Financial Counseling Financial counseling could also be called "financial investigation", as it is the method through which the provider identifies actual payment sources and alternatives.
Fiscal Intermediary Fiscal intermediary generally refers to an organization contracted with the Health Care Financing Administration (HCFA) Centers for Medicare and Medicaid Services (CMS) to process and pay Medicare UB-04 claims.
Form Locator Form Locator (FL) is the name of the data fields on each of the uniform bills(UB-04). The UB-04 has 81 numerically sequenced form locators, while the 1500 has 33 form locators.Sometimes the form locators are referred to as boxes, such as Box 1, Box 4.
Gatekeeper primary care physician responsible for overseeing and coordinating all aspects of a patient's medical care.
Group Health Plan Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity such as AARP.
Guarantor The responsible party for payment of services that may not be covered by a third party.
Guardian A person who is responsible for the care and/or property of another.
HCFA 1450 AKA UB92 – Medicare Part A claim filing form used for inpatient and outpatient encounters. It is standardized for use when submitting claims for Medicare A services.
HCFA 1500 Standardized form used to submit claims for Medicare Part B services.
Health Care Financing Administration (HCFA ) Health Care Financing Administration (HCFA) was the name of the administrative branch within the Department of Health and Human Service that was responsible for the Medicare and Medicaid programs.
Health Employer Data and Information Set (HEDIS) A set of performance measures designed to standardize the way health plans report data to employers.
Healthcare Common Procedure Coding System (HCPCS) The Healthcare Common Procedure Coding System (HCPCS) is a medical code set using Current Procedural Terminology 4 (CPT 4), alphanumeric, and local codes to identify health care procedures, equipment and supplies for claims submission
Health and Human Services (HHS) Administrative department of the federal government with responsibility for the Centers for Medicare and Medicaid Services (CMS), Health Care Financing Administration (HCFA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Health Insurance Claim Number (HICN) Health Insurance Claim Number – official name for Medicare Number.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Act of 1996 federal law /goal -persons to qualify immediately for comparable health ins cov when they change their employment relationships. Title I, subtitle F, of HIPAA gives (HHS) the authority to mandate the use standards for the electronic exchange
Health Maintenance Organizations (HMO) offer prepaid, comprehensive health coverage to their enrollees by contracting with hospitals, physicians, and other health professionals for their services.
Hospice Care that can be provided within the home for terminally ill patients and their families- provides a support system to patients and families who choose to share their last days together in the comfort of their home or other like setting.
(ICD-CM) is based on the official version of the World Health Organization’s Ninth Revision International Classification of Diseases (ICD-9), the most widely used classification system for the study of disease in the world today.
ICON A small picture on a computer screen representing a function or program.
Important Message from Medicare Indemnity (IMM) Medicare explanation to patients regarding their discharge and their discharge rights, including instructions on how to appeal if they feel they are being discharged too quickly.
Indemnity A health insurance plan in which patients may select any doctor or hospital and providers bill the patient or the insurance company their normal fees for their services. Providers have no relationship with the health plan.
Indemnity Coverage is usually provided only for diagnostic tests or conditions caused by disease, illness or injury. Routine screening or will visits are not always covered under traditional indemnity plans. (“Fee-for-service” is sometimes used as a synonym.)
Independent Practice Association (IPA) is a health maintenance organization delivery model in which the Health Maintenance Organization (HMO) contracts with a physician organization which, in turn, contracts with individual physicians
Inpatient A patient who is admitted for an expected overnight stay or for at least 24 hours and is provided with room, board, and continuous general nursing services for diagnostic, surgical or medical reasons.
Insurance Verification The process of determining coverage availability and benefits of coverage.
Insured The individual who is the holder of healthcare coverage through an insurance policy. Also employer, private health plan, or other payor can be called the insured, subscriber, policyholder or subscriber or sponsor.
Insurer health insurance plan or another entity that processes and pays healthcare bills may be called a third party payor, payor, carrier
Interface A program that passes information from one system to another
Intermediary A private business, typically an insurance company, which contract with Centers for Medicare and Medicaid Services (CMS) to receive, review and pay hospital and other institutional provider benefit claims.
Internet The Internet, or World Wide Web (www), is an on-line computer network connecting companies, universities, government agencies, healthcare systems, networks, and users, etc.
Itemized Statement An itemized statement is the record maintained by the health facility, hospital or physician’s office that details the charges made for services rendered to patients and shall indicate whether an assignment of benefits has been obtained
(JCAHO) an independent, not-for-profit organization, and the nation's oldest and largest standards setting and health care accrediting body.
Length of Stay (LOS) The length of a patient’s stay in a hospital or other health facility. Only the admission date is counted; the discharge date is not included in the count.
Liability Insurance Refers to insurance coverage (including a self-insured plan) that provides payment based on legal liability for injury, illness or damage to property.
Lifetime Reserve Days (LRD) Lifetime reserve days (LRD) is the term for Medicare Part A coverage that entitles the beneficiary to sixty days of inpatient coverage beyond the coinsurance day benefit period.
Long Term Care provided to the chronically ill/disabled in a nursing facility or rest home. Among the services provided by nursing facilities: 24-hour nursing care, rehabilitative services such a PT OT ST, as well as assistance with activities of daily living.
Managed Care system where care is sharply controlled through the use of a "gatekeeper" or prior aut process- plan usually involves a PPO) in which the patient has to use a provider contracted with the insurer to accept an agreed on fee
Master Patient Index (MPI is a comprehensive list of all patients and their key identifiers/ or Corporate Person Index (CPI) houses the Patient's medical record number and other key demographic information.
Medicaid joint Federal and State program that is administered and operated individually by each participating state government.
Medical Record is a clinical record of the services, results of tests, and progress notes associated with a patient visit.
Medical Record Number A number that uniquely identifies a patient. Used as the primary identifier on the patient’s chart and other medical documentation.
Medically Necessary extent/types of service or supplies that/represent appropriate medical care/generally accepted by qualified professionals as reasonable/adequate for the DX and TX of illnes/injury/maternity care.Many payors have their own panel of professionals/experts
Medicare A nationwide, federally administered health insurance program authorized to cover the cost of hospitalization, medical care, and some related services for the elderly, disabled persons received ssn benefits/ ersons with ESRD.
Medicare Choice Plan health plan, such as a Health Maintenance Organization (HMO) or Private Fee-for-Service plan, offered by a private company and approved by Medicare.
Medicare Secondary Payor (MSP) Centers for Medicare and Medicaid Services (CMS) have identified several circumstances when Medicare pay second
Medicare Summary Notice (MSN) Monthly statement listing Medicare claims information. It replaces the Explanation of Your Medicare Part B Benefits (EOMB), the Medicare Benefits Notice (Part A) and benefit denial letters.
Medicare Supplement An insurance policy that will pay all or part of the patient’s responsibility after Medicare pays
Medigap Insurance Medigap Insurance is Medicare supplemental insurance. It is private insurance that is designed to help pay Medicare costsharing amounts such as Medicare's coinsurance and deductibles, and uncovered services
Members Participants in a health plan (subscriber, enrollees, and eligible dependents) that make up the plan’s enrollment.
National Association of Insurance Commissioners (NAIC) An Association of the insurance commissioners of the states and territories
National Correct Coding Initiative (CCI) Established uniform standards for billing with Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS) codes
Network An organized group of physicians, hospitals and other healthcare providers working with the health plan to offer quality care at negotiated rates (lower than usual charges) in return for patient flow
Newborns' and Mothers' Health Protection Act A federal law which mandates that coverage for hospital stays for childbirth generally cannot be less than 48 hours for normal deliveries or 96 hours for cesarean births.
No Balance Billing Provision A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts (except for co-payments, coinsurance and deductibles).
Non-Availability Statement A statement issued by a uniformed service hospital when medical care is not available at their institution and the patient must use civilian healthcare. This applies for Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Patients.
Non-Plan Provider A health care provider without a contract with an insurer. Similar to a nonparticipating provider under Medicare.
Nurse Practitioner (NP) A nurse who has 2 or more years of advanced training and has passed a special exam.
Observation Care Those services furnished on a hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff/ usually do not exceed 24 to 48 hours.
Occupational Safety and Health Administration (OSHA) The mission of the Occupational Safety and Health Administration (OSHA) is to save lives, prevent injuries and protect the health of America's workers.
Office of the Inspector General (OIG) (Department of Health and Human Services). (CMS) enforcement arm whose mandate is to fight waste, fraud, and abuse. Inspectors General are appointed by the agency that monitors compliance in the healthcare industry.
Omnibus Budget Reconciliation Act (OBRA) Many federal regulations that impact healthcare financing are the result of budget legislation. Ambulatory Payment Classification’s (APC) were mandated by this act.
Open Access A self-referral arrangement allowing members to see participating providers for specialty care without a referral form another doctor.
Outlier One who does not fall within the norm; a term typically used in utilization review. A provider who uses either too many or too few services (example, anyone whose utilization differs two standard deviations from the mean on a bell curve is termed an
Out of Network Physicians or healthcare delivery systems that are not contracted to provide services covered by a specific health plan.
Out-of-Pocket The amount the patient/guarantor is responsible for paying for the service received at the hospital can be called out-of-pocket responsibility.
Out-Of-Pocket Maximums Dollar amounts set by Managed Care Organizations (MCO) that limit the amount a member has to pay out of his or her own pocket for particular health care services during a particular time period.
Outpatient Care Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility. An individual who receives healthcare services without being admitted as an inpatient to the hospital.
Outpatient Prospective Payment System (OPPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients who have no Part A coverage, and partial hospitalization services furnished by community mental health centers
Palliative Care Palliative care is active total care of patients who have advanced illnesses no longer amenable to curative treatment. Control of symptoms, such as pain, is the focus of treatment rather than prolongation of life.
Part A (Medicare) covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.
Part B (Medicare) insurance helps pay for doctors' services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Medicare Part A.
Participating Physician A physician contracting with the payor's managed care program to render services to members as a primary care or specialty care physician or as a consulting physician.
Patient Bill of Rights report prepared by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry in an effort to ensure the security of patient information, promote health care quality, and improve the avail. treatment and services.
Patient Liability The dollar amount that an insured individual is legally obligated to pay for services rendered by a provider.
Payor A health insurance plan or another entity that processes and pays healthcare bills may be called a third party payor, payor, carrier, or insurer.
PRIMARY: The initial payor to be billed for services.
SECONDARY Payor who is billed for charges not covered by the Primary payor.
TERTIARY Payor who is billed for charges not covered by the Primary or Secondary Payor
Peer Review The analysis of a clinician's care by a group of that clinician's professional colleagues.
Peer Review Organizations (PROs) According to the Balanced Budget Act of 1997, organizations or groups of practicing physicians and other health care professionals paid by the federal government to review and evaluate the services provided by other practitioners
Per Diem A negotiated daily payment for delivery of hospital services provided; sometimes refers only to “room and board” charges (meals, routine nursing care, etc.), and may or may not include ancillary services.
Physician’s Assistant (PA) is a health care professional licensed, or in the case of those employed by the federal government they are credentialed, to practice medicine with physician supervision
Point of Service Plan (POS) An option offered by a Health Maintenance Organization (HMO) to allow enrollees to use non-HMO providers on occasion. Enrollees select a Primary Care Physician (PCP) and incur little or no out-of-pocket cost.
Policyholder Subscriber of an insurance carrier also called insured. The individual who initiates healthcare coverage through an employer, private health plan, or other payor can be called the insured, subscriber, policyholder, or sponsor.
Pre-admission The process of creating a registration record for a future inpatient service. Commonly known as a “preadmit”.
Pre-Admission Certification Pre-Admission Certification is the process of assuring that financial prerequisites, such medical necessity, have been met. It does not guarantee payment.
Pre-existing condition Medical condition for which diagnosis or treatment was received within a fixed time period prior to enrollment in a group health. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), that time period is limited to six months.
Preauthorization The requirement of most managed care plans to obtain permission from the plan to perform certain outpatient tests or procedures.
Predetermination administrative procedure whereby a health provider submits at treatment plan to a third party before treatment is initiated. 3rd party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service
Preferred Provider Network (PPN) A network of physicians and healthcare organizations that provide services to a health plan's members.
Preferred Provider Organizations (PPO) form of managed care health benefit arrangements designed to provide benefits at a reasonable cost by providing its members with incentives to use designated healthcare providers.
Preferred Provider Plan (PPP) An insurance plan that participates in a preferred provider network.
Premium Regularly scheduled payment for insurance coverage to Medicare, an insurance company, or a health plan.
Primary Care Network (PCN) A group of primary care physicians who have joined to share the risk of providing care to their patients who are covered under a given health plan.
Primary Care Physician (PCP) The physician chosen by an insured to coordinate his or her care under a health maintenance organization (HMO) or point of service (POS) plan.
Primary Medical Group (PMG) A group of physicians in practice together who contract with an insurance company to coordinate a patient’s medical care. The group may consist of primary care physicians and specialists
Primary Payor Primary payor is the insurer or entity with first priority for payment of a bill.
Prior Authorization Services that require approval from the insurance company or Primary Care Physician (PCP) prior to the service being performed.
Professional Services Charges generated for physician services including outpatient office visits and services provided during an inpatient stay. The charges for professional fees are billed separately from the charges for hospital services.
Prospective Payment System (PPS) means that the payment to the provider is determined in advance and on diagnosis and procedure rather than being retrospectively determined and based on actual charges. In 1983 the Health Care Financing Administration (HCFA) implemented
Protected Health Information (PHI) All medical records and other individually identifiable health information used or disclosed by a covered entity in any form, whether electronically, on paper, or orally, are covered by the final rule.
Recidivism The frequency of the same patient being re-admitted to the hospital for the same health condition.
Recurring Visit series of visits for the same purpose, such as physical therapy, occupational therapy, radiation therapy, etc. Typically billed on a monthly basis.
Referral A form (may be electronic) used in managed care plans for the Primary Care Physician’s (PCP) authorization for certain specialist and certain services. Some plans may allow physicians other than PCP’s to provide referrals.
Referring Physician Physicians whose care or reference leads to services being provide by a healthcare facility.
Reimbursement Reimbursement is the amount of cash paid to the hospital by Patients and third party payors for healthcare services.
Rejection, Claim A refusal by a third-party payor to pay or consider a claim.
Rejection, Computer An electronic transaction that fails to update a system – i.e. an Admission Transfer Discharge transaction
Relative Value Scale A list of procedure codes that uses units to indicate the relative value of medical services performed by physicians. This coding system is used in many states for billing worker's compensation claims.
Respite Care Short-term care provided at home, in a long-term care facility, at a community based center, or in a hospital when another setting= family members time off in their care giving responsibilities. is not available
Revenue Code Codes established by the Health Care Financing Administration (HCFA) submitted on HCFA standard forms to identify hospital and ancillary services- defined as the charges generated as patients are given care.
Revenue Cycle All administrative and clinical functions that contribute to the capture and presentation of patient services for payment.
Risk (contract) A contractual agreement where all healthcare services are provided for a fixed monthly payment for all members enrolled. The providers are at financial risk for all services that are provided.
Routine A standard set of procedures or activities.
Self-Administered Drugs (SAD) Self-administered drugs (SAD) are oral or topical medications identified by Medicare as drugs that can be administered by the Patient in an outpatient setting and are not payable by Medicare.
Self-Funded Plan Managed Care Organization (MCO) or insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a selfinsured plan.
Self-Pay That portion of the bill that is to be paid in part or in full by the responsible party from their own resources, as it is not payable by a third party
Share of Cost (SOC) The amount a patient covered by Medicaid must pay for eligible medical expenses out of his or her pocket. The amount varies according to the patient’s current maintenance or financial status.
Skilled Nursing Facility (SNF) facility which primarily provides inpatient skilled nursing services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
Sponsor The individual who initiates healthcare coverage through an employer, private health plan, or other payor can be called the insured, subscriber, policyholder, or sponsor.
Standard of Care A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
State Children’s Health Insurance Program (SCHIP) A program for uninsured children in the United States that is administered by Centers for Medicare and Medicaid Services (CMS) in conjunction with the Health Resources and Services Administration.
State Health Insurance Assistance Program (SHIP) A State organization that receives money from the Federal Government to give free health insurance counseling and assistance to Medicare beneficiaries.
Stop-loss Provision A form of contracted payment that allows for a higher claim payment for a qualifying catastrophic hospitalization.- After an account hits $100,000.00, the hospital may receive 80% of its charges in lieu of the negotiated per diem or case rate payment.
Subscriber The individual who carries the insurance initiates healthcare coverage, through an employer, private health plan, or other payor can be called the insured, subscriber, or policyholder. Also referred to as the insured, or sponsor.
Supplemental Policy Secondary insurance is designed to decrease the patient obligation after primary insurance has been processed.
Tertiary Care The third level of care provided to patients requiring the most complex and sophisticated medical techniques and technologies (e.g., organ transplants, neonatal specialties, etc.)
Tertiary Payor Tertiary payor designation is the insurer or entity with third priority for payment of a bill, after the primary and secondary payors.
Third Party Administrator (TPA) An organization that administers health insurance plans or claims but does not assume the risk.
Third Party Payor A health insurance plan or another entity that processes and pays healthcare bills may be called
Tracking Number A number given by the insurance company or a third party payor as confirmation of receiving a notification of a patient’s admission or surgery.
Transaction A transaction is a data exchange of information
Tricare Department of Defense's health care program for members of the uniformed services, their families and survivors
UB-92 Uniform bill mandated by the Centers for Medicare and Medicaid Services (CMS) for use by hospitals, skilled nursing facilities, home health agencies, community mental health facilities, etc. This was replaced by the UB-04 in 2007.
Unique Physician Identification Number (UPIN) Required for Medicare and Medicaid billing. A physician or supplier that bills Medicare for a service or item must show the name and the
Urgent Care (UC) Urgently needed medical attention that may be provided in a setting other than an emergency department.
Usual, Customary and Reasonable (UCR) The amount a health plan will recognize for payment for a particular medical procedure. It is typically based on the average or prevailing fees for a specific service within a given geographical area.
Utilization Management (UM) The monitoring and controlling of healthcare services provided to a particular patient population to assure cost effective, quality care.
Waiver An amendment to a health insurance policy that excludes coverage for a specific condition. An agreement to give up a legal right.
Window A rectangular area shown on a computer screen to display data including drop down menus.
Workers’ Compensation Services where benefits are in whole or in part either payable or required to be provided under Workers’ Compensation or Occupational Disease law. California has a no fault system
Created by: Copa



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