Term | Definition |
fraud | intentional deception or misrepresentation that could result in an unauthorized payment |
abuse | actions inconsistent with accepted, sound medical, business, or fiscal practices |
scope of practice | health care services, determined by the state, that an NP and PA can perform |
respondent superior | Latin for "let the master answer"; legal doctrine holding that the employer is liable for he actions and omissions of employees performed and committed within the scope of their employment |
Statute of limitations | a statute prescribing a period of limitations for bringing |
subpoena | an order of the 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 of service. |
medical malpractice insurance | a type of liability insurance that covers physicians and other health care 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 (e.g., disease, injury, sign, symptom, other reason from encounter) that justifies the need to perform that procedure or serve |
preauthorization | prior approval |
remittance advice(remit) | electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges |
coinsurance | also called coinsurance payment; the percentage the patient pays for covered serves after the deductible has been met and the copayment has been paid |
ABN | Advance Beneficiary Notice |
ADA | Americans with Disabilities Act |
CHAMPUS | Civilian Health and Medical Program of the Uniformed Services |
CMS | Centers for Medicare and Medicaid Services |
CMS 1500 | Insurance claim used by non-institutional and other selected providers and suppliers to bill payers |
COBRA | Consolidated Omnibus Reconciliation Act |
CPT | Current Procedural Terminology |
DEERS | Defense Enrollment Eligibility Reporting System |
DME | Durable Medical Equipment |
DRG | Diagnosis Related Group |
EDI | electronic data interchange |