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Insurance terms

terms and acronyms

fraud intentional deception or misrepresentation that could result in an unauthorized payment
abuse actions inconsistent with accepted, sound medical, business, or fiscal practices
scope of practice health care services, determined by the state, that an NP and PA can perform
respondent superior Latin for "let the master answer"; legal doctrine holding that the employer is liable for he actions and omissions of employees performed and committed within the scope of their employment
Statute of limitations a statute prescribing a period of limitations for bringing
subpoena an order of the court that requires a witness to appear at a particular time and place to testify
stand-alone code CPT code that includes a complete description of the procedure of service.
medical malpractice insurance a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment
medical necessity involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason from encounter) that justifies the need to perform that procedure or serve
preauthorization prior approval
remittance advice(remit) electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges
coinsurance also called coinsurance payment; the percentage the patient pays for covered serves after the deductible has been met and the copayment has been paid
ABN Advance Beneficiary Notice
ADA Americans with Disabilities Act
CHAMPUS Civilian Health and Medical Program of the Uniformed Services
CMS Centers for Medicare and Medicaid Services
CMS 1500 Insurance claim used by non-institutional and other selected providers and suppliers to bill payers
COBRA Consolidated Omnibus Reconciliation Act
CPT Current Procedural Terminology
DEERS Defense Enrollment Eligibility Reporting System
DME Durable Medical Equipment
DRG Diagnosis Related Group
EDI electronic data interchange
Created by: lynn559