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wk4 InsTerms/Acronym
| Term | Definition |
|---|---|
| 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
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