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MOP110 Ins. Terms

Abuse Actions incincistant with accepted sound medical. business or fiscal practices.
Fraud Intentional deception or misrepresentation that could result in a unauthorized payment
Scope of Practice Healthcare services determined by a state, that a NP and PA can perform
Respondent Superior Latin for " Let the Master Answer"; legal doctrine that the employer is liable for the action & omission of employees performed & committed within the scope of their employment
Statue of Limitations a statue prescribing a period of limitation for bringing certain kind of legal action
Subpoena an order of a court that requires a witness to appear at a particular time and 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 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 has been met & the copayment has 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 policyholder or patient to pay specified dollar amount to a healthcare provider for each visit or medical 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 provide to patients ( fee assigned to each CPT code)
PolicyHolder a person who signs a contact 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 own & 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 has met standards beyond those required by law.
Capitation provider accepts pre-established payments if the healthcare services to enrollees over a period of time. ( usually Fee of one year )
Fee for service reimbursement methodology that increases payment if the health care services fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services
Gag Clause prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement of services.
Gatekeeper PCP for essential health care services at the lowest possible cost, avoiding nonessential care & referring patient to specialist
Accept Assignment provider accepts as payment in full what ever is paid on the claim by the payer
Allowed Charges that maximum amount that payer will reimburse for each procedure or service according to the patient's policy
Assignment of Benefits the provider receives reimbursement directly from 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 charge for each; Charge master data are entered in the facility patient accounting system & charges are automatically posted to patient bill (UB-04)
adjudication judicial dispute resolution process in which an appeals board makes a final determination
Appeal documented as a letter , signed by a provider , explaining why claim should be reconsidered
Clean Claim A Clean Claim is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable Security Health Plan to process the claim.
Clearinghouse an agency or organization that collects and distributes something, especially information.
Downloading assigning lower-level codes than documented in the record
Guarantor person responsible for paying health care fees
Litigation legal action to recover debt; usually the last resort for physicians medical practice
Superbill term used for an encounter form in a physicians office
unbundling submitting multiple CPT codes when one code should be determined
Confidentiality restriction of patient information to those who do not proper authorization to secure the patience information
Upcoding Assignmenet of an ICD-10CM diagnosis code that does not match the procedure or services for t he patient increasing reimbursement
Dual Eligible Individuals entitled to Medicare and eligible for some type of Medicaid benefit
Arbitration dispute resolution process in which a final decision is made by an impartial person who may nopt have judicial powers
Created by: IzzyMOA
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