Medicare Terms
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| ABN - Advance Beneficiary Notice | Form used to notify patients in advance that a service may not be covered and the patient may be responsible. Medicare patients only - they require this form
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| Actual Charge | The amount a physician or supplier actually bills patient for a particular service or supply.
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| Appeal | Complaint beneficiaries make if they disagree with any decision about their health care services
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| Appellant | An individual who appeals a claim decision
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| Approved Amount | The (most) amount an insurance carrier deems reasonable for the billed (actual) charges
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| Assigned Claims | A claim form that directs payment to the provider/supplier
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| Assignment of Benefits | Authorization for the insurance company to send insurance payments directly to the health care provider also, an agreement with Medicare that the (participating) provider will accept the remittance as full pmt.
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| Audit | Process to ensure that Medicare reimburses provider based only on cost associated with patient care. To go over the records - to make sure it is billed correctly
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| Beneficiary | A person eligible to receive insurance benefits
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| Claim | Request for payment of Medicare benefits or services rendered by a provider
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| CMS Centers for Medicare and Medicaid Services | Administers and oversees the Medicare program and a portion of the state Medicaid program
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| 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. (supplemental Ins.
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| Co-Insurance | The Medicare co-pay paid by the patient for services. It is sometimes referred to as a co=payment
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| CPT Current Procedural Terminology | System of uniformed medical procedure codes to identify specific health care services
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| Deductible | The amount that must be paid by a beneficiary before an insurer begins to pay for medical services
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| DRG Diagnostic Related Groups | (Question of Cert Exam)!
Classification of diagnoses used to determine hospital payment for Medicare in patients.
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| ESR End Stage Renal Disease | Kidney failure that is severe enough to require lifetime dialysis or a kidney transplant.
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