insurance terms part 3
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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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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