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Insurance Terms vol3
MOP 110 Ms. Ragadio
Term | Definition |
---|---|
accept assignment | : provider accepts as payment in full whatever is paid on the claim by the payer. |
allowed charges | the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy. |
assignment of benefits | the provider receives reimbursement directly from the payer. |
beneficiary | the person eligible to receive health care benefits. |
birthday rule | determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. |
charge master | document that contains a computer generated list of procedures, services, and supplies with charges for each. |
adjudication | judicial dispute resolution process in which an appeals board makes a final determination. |
appeal | documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment. |
clean claim | a correctly completed standardized claim. |
clearinghouse | performs centralized claims processing for providers and health plans. |
downcoding | assigning lower-level codes than documented in the record. |
guarantor | person responsible for paying health care fees. |