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Ch.5 UHI
Understanding Health Insurance Ch.5
| Term | Definition |
|---|---|
| National Drug Code | maintained by the FDA; identifies prescription drugs and some OTC products. |
| Health Plan Identifier | unique identifier is assigned to 3rd party payers. |
| subpoena | an order of the court that requires a witness to appear at a particular time and place to testify. |
| medical review | a review of claims to determine whether services provided are medically reasonable and necessary. |
| upcoding | assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement. |
| National Provider Identifier | unique identifier to be assigned to health care providers. |
| deposition | legal proceeding during which a party answers questions under oath. |
| breach of confidentiality | unauthorized release of patient information to a 3rd party. |
| confidentiality | restricting patient information access to those with proper authorization and maintaining the security of patient information. |
| overpayment | funds that a provider or beneficiary has received in excess of amounts due and payable under Medicare and Medicaid statutes and regulations. |
| interrogatory | documents containing a list of questions that must be answered in writing. |
| abuse | actions inconsistent with accepted, sound medical business, or fiscal practices. |
| privileged communication | private information shared between a patient and health care provider. |
| qui tam | who as well for the king as for himself sues. |
| civil law | area of law not classified as criminal. |
| authorization | document that provides official instruction. |
| 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&B and DMEPOS. |
| privacy | right of individuals to keep their information from being disclosed to others. |
| fraud | intentional deception or misrepresentation that could result in an unauthorized payment. |
| criminal law | public law governed by statute or ordinance that deals with crimes and their prosecution. |
| case law/common law | based on a court decision that establishes a precedent. |
| whistleblower | individual who makes specified disclosures relating to the use of public funds. |
| medical identity theft | occurs when someone uses another person's name and/or insurance information to obtain medical and/or surgical treatment, prescription drugs, and MDE. Can also occur in a medical setting. |
| listserv | subscriber-based questions-and-answer forum that is available through email. |
| subpoena duces tecum | requires documents |
| decrypt | to decode an encoded computer file so that it can be viewed. |
| UB-04 | insurance claim or flat file used to bill institutional services, such as services performed in hospitals. |
Created by:
wendylou421
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