Legal Aspects of Health Insurance and Reimbursement
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| show | also called statutory law; laws passed by legislative bodies (e.g., federal Congress and state legislatures).
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| regulations | show 🗑
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| show | also called common law; based on a court decision that establishes a precedent.
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| precedent | show 🗑
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| Civil law | show 🗑
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| subpoena | show 🗑
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| show | requires documents (e.g., patient record) to be produced.
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| deposition | show 🗑
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| interrogatory | show 🗑
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| Qui tam | show 🗑
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| Federal Register | show 🗑
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| show | document published by Medicare containing new and changed policies and/or procedures that are to be incorporated into a specific CMS program manual
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| show | an online CMS publication that contains information about regulations and major policies currently under development, regulations and major policies completed or canceled, and new or revised manual instructions.
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| Medicare administrative contractor (MAC) | show 🗑
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| show | health and safety regulations that health care organizations, such as hospitals, must meet in order to begin and continue participating in the Medicare and Medicaid programs.
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| show | health and safety regulations that health care organizations, such as end-stage renal disease facilities, must meet in order to begin and continue participating in the Medicare and Medicaid programs
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| show | storage of documentation for an established period of time, usually mandated by federal and/or state law
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| audit | show 🗑
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| show | internal policies and procedures that an organization follows to meet mandated requirements.
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| show | authorizes CMS to enter into contracts with entities to perform cost report auditing, medical review, anti-fraud activities, and the Medicare Secondary Payer (MSP) program.
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| show | defined by CMS as a review of claims to determine whether services provided are medically reasonable and necessary, as well as to follow up on the effectiveness of previous corrective actions.
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| show | combats fraud, waste, and abuse in the Medicaid program; Congress requires annual reporting by CMS about the use and effectiveness of funds appropriated for the MIP.
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| Medicaid integrity contractors (MICs) | show 🗑
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| show | investigates and prosecutes Medicaid provider fraud as well as patient abuse or neglect in health care facilities and board and care facilities in all 50 States
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| Recovery Audit Contractor (RAC) program | show 🗑
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| Health Care Fraud Prevention and Enforcement Action Team (HEAT) | show 🗑
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| show | mandated by the Patient Protection and Portable Care Act (PPACA) to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service
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| Health Insurance Portability and Accountability Act (HIPAA) | show 🗑
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| show | intentional deception or misrepresentation that could result in an unauthorized payment.
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| show | actions inconsistent with accepted, sound medical, business, or fiscal practices.
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| National Individual Identifier | show 🗑
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| National Provider Identifier (NPI) | show 🗑
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| National Standard Employer Identification Number (EIN) | show 🗑
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| National Plan and Provider Enumeration System (NPPES) | show 🗑
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| electronic transaction standards | show 🗑
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| show | application of a mathematical function to an electronic document to create a computer code that can be encrypted (encoded).
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| unique bit string | show 🗑
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| message digest | show 🗑
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| Encrypt | show 🗑
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| decrypts | show 🗑
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| show | electronic format supported for health care claim transactions.
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| UB-04 flat file | show 🗑
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| National Standard Format (NSF) | show 🗑
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| show | private information shared between a patient and health care provider; disclosure must be in accordance with HIPAA and/or individual state provisions regarding the privacy and security of protected health information (PHI).
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| show | information that is identifiable to an individual (or individual identifiers) such as name, address, telephone numbers, date of birth, Medicaid ID number, medical record number, Social Security number (SSN), and name of employer.
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| show | document that provides official instruction, such as the customized document that gives covered entities permission to use specified protected health information (PHI) for specified purposes
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| show | right of individuals to keep their information from being disclosed to others.
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| de-identification of protected health information | 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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| Security | show 🗑
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| show | unauthorized release of patient information to a third party.
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| show | HIPAA provision that creates national standards to protect individuals’ medical records and other personal health information.
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| show | activities defined by the HIPAA Privacy Rule, including treatment (provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care pro
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| show | document that includes an individual’s health privacy rights related to protected health information (PHI) and communicates how health information may be used and shared.
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| minimum necessary standard | show 🗑
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| show | group of records maintained by or for a covered entity and includes medical and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, claims adjudication, and case or medical management
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| HIPAA Security Rule | show 🗑
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| show | HIPAA rule that requires covered entities and their business associates to provide patient notification following a breach of unsecured protected health information.
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| show | occurs when someone uses another person’s name and/or insurance information to obtain medical and/or surgical treatment, prescription drugs, and medical durable equipment
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| show | HIPAA regulation that requires health care organizations to track medical information provided to third parties (e.g., attorneys, third-party payers, and Social Security disability offices)
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| show | ROI by a covered entity (e.g., provider’s office) about protected health information (PHI) requires the patient (or representative) to sign an authorization to release information
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| release of information log | show 🗑
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Created by:
Amaya122000