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insurance terms.3
insurance terms part 3
| Term | Definition |
|---|---|
| Accept Assignment | Provider accepts as payments in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts) |
| Adjudication | Judicial dispute resolution process in which an appeals board makes a final determination |
| Allowed Charges | The maximum amount the payer will reimburse for each procedure or service according to the patient's policy |
| Appeal | Documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment |
| Arbitration | Dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers |
| 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; chargemaster data are entered in the facility's patients accounting system, and charges are automatically posted to the patient's bill (UB-04) |
| Clean Claim | A correctly completed standardized claim (e.g., CMS-1500 claim) |
| Clearinghouse | Performs centralized claims processing for providers and health plans |
| Confidentiality | Restricting patient information access to those with proper authorization and maintaining the security of patent information |
| Downcoding | Assigning lower-level codes than documented in the record |
| Dual Eligible | Individuals entitled to Medicare and eligible for some type of Medicaid benefit |
| Guarantor | Person responsible for paying health care fees |
| Litigation | Legal action to recover a debt; usually a last resort for a medical practice |
| Superbill | Term used for an encounter form in the physician's office |
| Upcoding | Assignment of an ICD-10CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-10CM code for heart attack when angina was actually documented in the record.) |
| Unbundling | Submitting multiple CPT codes when one code should be submitted |
Created by:
1berev2
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