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Billing & Coding Ch2

HMO Health Maintenance Organization
Medical standards of care state-specified performance measures for healthcare delivery
Evaluation and Management (E/M) provider’s evaluation of a patient’s condition and decision on a course of treatment
Health Information Technology for Economic and Clinical Health (HITECH) Act a law with provisions concerning standards for electronic transmission of healthcare data
Health information exchange (HIE) makes it possible to share health-related information among provider organizations.
accountable care organizations (ACOs) a network of doctors and hospitals who share responsibility for managing quality and cost of care provided to a group of patients
Affordable Care Act (ACA) Health system reform legislation that offers improved insurance coverage and other benefits
Covered Entity (CE) Healthcare organization (health plan, clearinghouse, provider, or business associate) that transmits HIPAA- protected information electronically.
Clearinghouse Company that converts nonstandard transactions into standard transactions and transmits the data to health plans (and the reverse procedure)
Electronic data interchange (EDI) computer-to- computer exchange of data in a standardized format
Protected health information (PHI) individually identifiable health information transmitted or maintained by electronic media
Designated record set (DRS) CE’s records that contain PHI
Accounting for disclosure documentation of the disclosure of a patient’s PHI in that person’s medical record in unauthorized cases. 2-21
National Provider Identifier (NPI) unique ten-digit identifier assigned to each provider
Omnibus Rule set of regulations enhancing patients’ privacy protections and rights to information, and the government’s ability to enforce HIPAA
Compliance plan medical practice’s written plan for complying with regulations
Guarantor The individual that is responsible for paying any patient responsibility after the insurance has processed the claim
PPO a type of managed care organization where providers join the network and are considered preferred when patients seek treatment
Capitation an agreement with a provider to receive a pre-established payment for health care services to enrollees over a period of time
Deductible the annual amount the patient must pay before the insurance will begin to pay for covered benefits
COB coordination of benefits
Created by: shawnettadj
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