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Insurance Terms vol3

MOP 110 Ms. Ragadio

TermDefinition
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.
Created by: lolawhiterabbit