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Ch.5 UHI

Understanding Health Insurance Ch.5

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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