Terms and questions
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| ABN - Advance Beneficiary Notice | A form used to notify patients in advance that a service may not be covered and the patient may be responsible.
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| Approved Amount | the amount an insurance carrier deems rasonable fo the billed 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 coompany to send insurance payments directly to the health care provider also, an agreement with Medicare tht the provider will accept the remittance as full payment.
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| Audit | process to ensure that Medicare reimburses providers based only on cost associated with patient care.
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| Beneficiary | a person eligible to recieve insurance benefits.
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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.
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| Co-Insureance | the Meicare co-pay paid by the patient for services. It is sometimes referred to as a copayment.
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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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| Diagnostic-Related Groups (DRG) | classification of diagnoses used to determine hospital payment for Medicare impatients.
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| Fee Schedule | a physician's listing of all reimbursement fees for all procedures performed in the practice.
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| HICN - Health Insurance Claim Number | a ten to eleven digit number assigned by Medicare to its beneficiaries.
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| Medicaid | provides health coverage for the categorically needy.
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| Medicare | primaryily for people older than 65 and others eligible for social Security; federal insurance program established in 1965 under ssa
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| Medicare Managed Care Plans | these are health care choices such as HMO's Part C of the Medicare program.
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| Non-participating Physician | a physician who has not entered into a written agreement with an insurance company to accept the plan's fee for services rendered.
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| Participating Physician | a physician who has entered into a written agreement with an insurance company to accept the plan's fee for service rendered a payment in full.
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| Premium | a dollar amount the insured person pays for insurance coverage.
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| Resources-Based Relative Value System/Scale (RBRVS) | a system that calculates physician reimbursement for services using relative value units.
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| Remittance Notice | paper summarized statement for providers including payments/rejections for one or more beneficiaries
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| Medicare part A | Hospital, home healthcare, hospice, skilled nursing facilities
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| Medicare part B | medical,outpatient hospital care, medical equipment, physician services, other medical services,
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| One form of insurance abuse is | submitting a claim for unnecessary procedures
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| To be eligible for Medicare part C you must have | Part A & B or medicare
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| What is medicare part D | prescription drug program provided by private companies.
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| What is a contractual write off | difference between the actual charge and the allowed amount.
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| What is Utilization Review | is a review of individual cases by a committee to ensure services are medically necessary and to study how providers us medical resources.
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| Allowed Charges | The moset the payer will pay any provider for services. - cannot bill the patient for the difference
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| Contracted Fee Schedule | Fixed fee schedule - percentage of charges if any the patient owes and the what the payer covers - can bill the patient.
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| Capitation | a fixed prepayment - non covered services can be billed.
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