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wk4 InsTerms/Acronym

TermDefinition
accept assignment provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/ or coinsurance amounts.)
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; charge master data are entered in the facility's patient accounting system, and charges are automatically posted to the patient's bill
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 (e.g., CMS-1500 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
litigation legal action to recover a debt; usually a last resort for a medical practice
MAC Medicare administrative contractor
Medi-Medi Medicare/Medicaid crossover
MPFS Medicare Physician Fee Schedule
MS-DRG Medicare severity diagnosis-related group
nonPAR non participating provider
NPI National Provider Identifier
OBRA Omnibus Budget Reconciliation Act of 1981
OSHA Occupational Safety and Health Administration
OWCP Office of Workers Compensation Program
PAR Participating Provider
PCP Primary Care Provider
PHI Protected Health Information
PIN Provider Identification Number
POS Place of Service
PPO Preferred provider organization
RBRVS resource based relative value system
RVU relative value unit
SOAP subjective, objective, assessment, plan
Created by: cheri le