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Medicare Terms

ABN - Advance Beneficiary Notice Form used to notify patients in advance that a service may not be covered and the patient may be responsible. Medicare patients only - they require this form
Actual Charge The amount a physician or supplier actually bills patient for a particular service or supply.
Appeal Complaint beneficiaries make if they disagree with any decision about their health care services
Appellant An individual who appeals a claim decision
Approved Amount The (most) amount an insurance carrier deems reasonable for the billed (actual) charges
Assigned Claims A claim form that directs payment to the provider/supplier
Assignment of Benefits Authorization for the insurance company to send insurance payments directly to the health care provider also, an agreement with Medicare that the (participating) provider will accept the remittance as full pmt.
Audit Process to ensure that Medicare reimburses provider based only on cost associated with patient care. To go over the records - to make sure it is billed correctly
Beneficiary A person eligible to receive insurance benefits
Claim Request for payment of Medicare benefits or services rendered by a provider
CMS Centers for Medicare and Medicaid Services Administers and oversees the Medicare program and a portion of the state Medicaid program
COB Coordination of Benefits A program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan. (supplemental Ins.
Co-Insurance The Medicare co-pay paid by the patient for services. It is sometimes referred to as a co=payment
CPT Current Procedural Terminology System of uniformed medical procedure codes to identify specific health care services
Deductible The amount that must be paid by a beneficiary before an insurer begins to pay for medical services
DRG Diagnostic Related Groups (Question of Cert Exam)! Classification of diagnoses used to determine hospital payment for Medicare in patients.
ESR End Stage Renal Disease Kidney failure that is severe enough to require lifetime dialysis or a kidney transplant.
Created by: wenchie040