Insurance Terminology
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| Abuse | show 🗑
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| show | intentional deception or misrepresentation that could result in an unauthorized payment
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| show | health care services, determined by the state, that an NP and PA can perform
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| Statute of Limitations | show 🗑
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| Subpoena | show 🗑
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| show | CPT code that includes a complete description of the procedure or service
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| Medical Malpractice Insurance | show 🗑
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| Medical Necessity | show 🗑
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| show | prior approval
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| show | electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim HIC/TOB patient info, code remarks
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| show | also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid
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| show | documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment
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| Copayment | show 🗑
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| Deductible | show 🗑
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| Fee schedule | show 🗑
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| Policy Holder | show 🗑
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| Socialized Medicine | show 🗑
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| show | a health insurance company that provides coverage, such as BlueCross BlueShield
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| show | voluntary process that a health care facility or organization (hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
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| show | provider accepts pre-established payments for providing health care services to enrollees over a period of time (usually one year).
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| show | reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services
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| show | prevents from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services
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| Gatekeeper | show 🗑
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| Accept Assignment | show 🗑
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| show | the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
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| Assignment of Benefits | show 🗑
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| Beneficiary | show 🗑
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| show | determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan
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| show | document that contains a computer-generated list of procedures, services, and supplies with charges for each; chargemaster data are entered in the facility’s patient accounting system and charge are automatically poste to the patient’s bill
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| show | judicial dispute resolution process in which an appeals board makes a final determination
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| show | documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment
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| show | a correctly completed standardized claim (CMS-1500 claim)
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| Clearinghouse | show 🗑
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| show | assigning lower-level codes than documented in the record
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| Guarantor | show 🗑
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| Litigation | show 🗑
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| show | term used for an encounter form in the physician’s office
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| Unbundling | show 🗑
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| show | restricting patient information access to those with proper authorization and maintaining the security of patient information
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| show | assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (assigning the ICD-10-CM code for heart attack when angina was actually documented in the record)
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| Dual Eligible | show 🗑
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| show | dispute-resolution process in which a final determination is made by an impartial person who may not have judicial powers
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