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Medicare Insurance

Terms and questions

ABN - Advance Beneficiary Notice A form used to notify patients in advance that a service may not be covered and the patient may be responsible.
Approved Amount the amount an insurance carrier deems rasonable fo the billed charges.
Assigned Claims a claim form that directs payment to the provider/supplier.
Assignment of Benefits authorization for the insurance coompany to send insurance payments directly to the health care provider also, an agreement with Medicare tht the provider will accept the remittance as full payment.
Audit process to ensure that Medicare reimburses providers based only on cost associated with patient care.
Beneficiary a person eligible to recieve insurance benefits.
COB - Coordination of Benefits a program for determining which health insurer pays for services first when a beneficiary is covered by more than one health care plan.
Co-Insureance the Meicare co-pay paid by the patient for services. It is sometimes referred to as a copayment.
Deductible the amount that must be paid by a beneficiary before an insurer begins to pay for medical services.
Diagnostic-Related Groups (DRG) classification of diagnoses used to determine hospital payment for Medicare impatients.
Fee Schedule a physician's listing of all reimbursement fees for all procedures performed in the practice.
HICN - Health Insurance Claim Number a ten to eleven digit number assigned by Medicare to its beneficiaries.
Medicaid provides health coverage for the categorically needy.
Medicare primaryily for people older than 65 and others eligible for social Security; federal insurance program established in 1965 under ssa
Medicare Managed Care Plans these are health care choices such as HMO's Part C of the Medicare program.
Non-participating Physician a physician who has not entered into a written agreement with an insurance company to accept the plan's fee for services rendered.
Participating Physician a physician who has entered into a written agreement with an insurance company to accept the plan's fee for service rendered a payment in full.
Premium a dollar amount the insured person pays for insurance coverage.
Resources-Based Relative Value System/Scale (RBRVS) a system that calculates physician reimbursement for services using relative value units.
Remittance Notice paper summarized statement for providers including payments/rejections for one or more beneficiaries
Medicare part A Hospital, home healthcare, hospice, skilled nursing facilities
Medicare part B medical,outpatient hospital care, medical equipment, physician services, other medical services,
One form of insurance abuse is submitting a claim for unnecessary procedures
To be eligible for Medicare part C you must have Part A & B or medicare
What is medicare part D prescription drug program provided by private companies.
What is a contractual write off difference between the actual charge and the allowed amount.
What is Utilization Review is a review of individual cases by a committee to ensure services are medically necessary and to study how providers us medical resources.
Allowed Charges The moset the payer will pay any provider for services. - cannot bill the patient for the difference
Contracted Fee Schedule Fixed fee schedule - percentage of charges if any the patient owes and the what the payer covers - can bill the patient.
Capitation a fixed prepayment - non covered services can be billed.
Created by: jr87