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Insurance Terms


Abuse "Description" Actions inconsistent with accepted sound medical, business, or fiscal practices
Fraud Intentional deception or misrepresentation that could result in an unauthorized payment
Scope of Practice Healthcare services determined by state, that a NP & PA can perform
Respondent Superior Latin for "Let the Master Answer"; legal doctrine that the employer is liable for the actions & omission of employees performed & committed within the scope of their employment
Statue of Limitations a statue prescribing a period of limitation for bringing certain kinds of legal action
Subpoena An order of the court that requires a witness to appear at a particular time & place to testify
Stand Alone Code CPT code that includes a complete description of the procedure or service
Medical Malpractice Insurance A type of liability insurance that covers physicians & other healthcare professionals for liability claims arising from patient treatment
Medical Necessity Involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service
Preauthorization Prior approval
Remittance Advice, Remit Also called transaction rule; a uniform language for electronic data
Co-insurance Also called coinsurance payment; the percentage the patient pays for covered services after the deductible had been met & the copayment had been paid
Continuity of Care Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment
Copayment Provision in an insurance policy that requires the policy holder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received
Deductible Amount for which the patient is financially responsible before an insurance policy provides coverage
Fee schedule List of predetermined payment for healthcare services provided to patients ( fee assigned to each CPT code)
Policyholder A person who signs a contract with a health insurance company and who, thus, owns the health insurance policy; the policyholder is the insured (or enrollee) and the policy might include coverage for dependents
Socialized Medicine type of single-payer system in which the government owns & operates healthcare facilities & providers receive a salary; the VA is a form of this
Third-Party Payer a health insurance company that provides coverage, BCBS
Accreditation Voluntary process that a health care facility or organization, undergoes to determine that it had met standards beyond those required by law
Capitation Provider accepts pre-established payments for providing health care services to enrollees over a period of time (usually 1-year)
Fee for Service Reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of a less expensive services
Gag Clause Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
Gatekeeper PCP for essential health care services at the lowest possible cost, avoiding nonessential care & referring provide reimbursement for services
Accept Assignment Provider accepts as payment in full whatever paid on the claim by the payer
Beneficiary the person eligible to receive health care benefits
Birthday Rule Determines coverage by primary & secondary policies when each patient subscribes to a different health insurance plan
Chargemaster Document that contains a computer generated list of procedures, services, & supplies with charges for each; Chargemaster data are entered in the facility's patient accounting system & charges are automatically posted to patient's bill (UB-04)
Adjudication Judicial dispute resolution process in which an appeals board makes a final determination
Appeal Documented as letter, signed by the provider, explaining why a claim should be reconsidered for payment
Clean claim A correctly completed standardized claim (CMS-100)
Clearinghouse Performs centralized claims processing for providers & health plans
Downloading 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
Superbill Term used for an encounter from in a physician's office
Unbundling submitting multiple CPT codes when one code should be submitted
Confidentiality Restricting patient information access to those with proper authorization & maintaining the security of patient information
Upcoding Assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement
Dual Eligible Individuals entitled to Medicare and eligible for some type of Medicaid benefit
Arbitration Dispute resolution process in which a final determination is made by an impartial person who may not have judicial powers
Allowed Charges That 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
Created by: Cristinacholi
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