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insurance terms.3

insurance terms part 3

TermDefinition
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