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insurance terms part 3

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Term
Definition
Accept Assignment   Provider accepts as payments in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts)  
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Adjudication   Judicial dispute resolution process in which an appeals board makes a final determination  
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Allowed Charges   The maximum amount the payer will reimburse for each procedure or service according to the patient's policy  
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Appeal   Documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment  
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Arbitration   Dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers  
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Assignment of Benefits   The provider receives reimbursement directly from the payer  
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Beneficiary   The person eligible to receive health care benefits  
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Birthday Rule   Determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan  
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Charge Master   Document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility's patients accounting system, and charges are automatically posted to the patient's bill (UB-04)  
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Clean Claim   A correctly completed standardized claim (e.g., CMS-1500 claim)  
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Clearinghouse   Performs centralized claims processing for providers and health plans  
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Confidentiality   Restricting patient information access to those with proper authorization and maintaining the security of patent information  
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Downcoding   Assigning lower-level codes than documented in the record  
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Dual Eligible   Individuals entitled to Medicare and eligible for some type of Medicaid benefit  
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Guarantor   Person responsible for paying health care fees  
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Litigation   Legal action to recover a debt; usually a last resort for a medical practice  
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Superbill   Term used for an encounter form in the physician's office  
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Upcoding   Assignment of an ICD-10CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-10CM code for heart attack when angina was actually documented in the record.)  
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Unbundling   Submitting multiple CPT codes when one code should be submitted  
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