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Acceptance of assignment Under governmental health care programs, a physician's agreement to accept the allowed charge as payment in full. Acute Refers to a medical condition that runs a short but relatively severe course. May also refer to a sudden exacerbation of a chronic condition. Advance beneficiary notice Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program. Allowed charge The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms. Ancillary services Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests. Appeal Request for more payment made by asking for a review of an insurance claim that has been paid or denied by and insurance company. Applicant Person applying for insurance coverage Approved charges Fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the difference. Assignment of benefits Permission granted by the insured that allows the insurance company to send the amount paid directly to the physician, health care provider, hospital, or nursing facility. If the patient does not sign the assignment of benefits, the insurance benefit check goes to the policyholder. Attending physician Medical staff member who is legally responsible for the care and treatment given to a patient. Benefits The amount of money a health plan pays for services covered in an insurance policy. Benefit period Period of time for which payments for Medicare inpatient hospital benefits are available. A benefit period begins the first day an enrollee is given inpatient hospital care (nursing care or rehabilitation services) by qualified provider and ends when the enrollee has not been inpatient for 60 consecutive days. For disability insurance, it is the maximum amount of time that benefits will be paid to the injured or ill person for a disability. Bilateral When coding surgical procedures, this term refers to both sides of the body. Birthday rule The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary Capitation System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. Catastrophic cap Under limit that an active-duty family has to pay under TRICARE Standard-covered medical bills in any fiscal year. Categorically needy Aged, blind, or families and children who meet financial eligibility requirements for Aid to Families with Dependent Children, Supplemental Security Income, or and optional state supplement. Center for Medicare and Medicaid Services The governmental department that runs Medical and other governmental health programs. Chief complaint Patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician. Chronic Medical condition persisting over a long period of time. Claim Request for payment of a covered medical expense, sent to the insurance company, may be submitted by the insured or by the agency or individual that provided the medical care. Coexisting condition Additional illness that either has an effect on the patient's primary illness or is also treated during the encounter. Coinsurance Portion of covered charges the insured must pay beyond any applicable deductible. It is a specified percentage of each fee for a covered service the patient must pay to provider (for Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible). Compliance program A management plan composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical record keeping that fulfills official requirement. Consultation Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem. Coordination of benefits Health insurance policy clause that applies to an individual covered by more than one medical insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim. Copayment Provision in an insurance policy requiring the policy holder or patient to pay a specified dollar amount to a health care provider for each visit or medical service they receive. Crossover claim Claim for services to a Medicare/Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer. Deductible Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually annual amount per individual or family Dependent Person(s) financially supported by the insured; ie spouse, children, and others as described in the policy. Durable Medical equipment Medicare term for reusable physical supplies such as wheelchairs and hospital beds that are ordered by the provider for use in the home; reported with HPCPS Level II codes. Early and Periodic Screening Diagnosis, and Treatment Medicaid's prevention, early detection, and treatment program for eligible children under the the age of 21. Emancipated Minor Person younger than 18 years of age who lives independently, is totally self-supporting, is married or divorced, is a parent even if not married, or is in the military and possesses decision-making rights. Eponym A condition or procedure named after a person or place. Established Patient Individual who has received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years. Excluded service A service specified in a medical insurance contract as not covered. Explanation of benefits A recap sheet that accompanies an insurance checks showing the breakdown and explanation of payments on a claim. Fee-for-service Method of charging under which a provider's payment is based on each service performed. Fee schedule A list of charges for services performed Fiscal intermediary A governmental contractor that processes claims for governmental programs. (For Medicare the fiscal intermediary processed Part A claims. Formulary A list of a health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists. Group contract Health insurance policy purchased by an organization or corporation that covers a defined group of individuals and eligible dependents; e.g the employees of an organization/corporation or members of a union or professional association. Guarantor An individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatment constitutes an expressed promise. Major Medical Health insurance policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury. Managed Care A system that combines the financing and the delivery of appropriate, cost-effective health care services to its members. Medical necessity Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient's symptoms and diagnosis. Medically indigent A classification of Medicaid recipient that includes people who can pay for basic living expenses but cannot pay high medical bills. Medicare Part A The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care. Medicare Part B The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. Medigap insurance An insurance plan offered by a federally approved private insurance carrier designed to supplement Medicare coverage. New Patient Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years. No Charge Waiving of the entire fee owed for professional services. Nonparticipating physician A physician or other health care provider who chooses not to join particular government or other program or plan. Out-of-network Providers or suppliers who do not participate in a managed care organization or health plan. Out-of-pocket Expenses the insured must pay before benefits begin. Outpatient Term used when an individual receives medical service from the hospital and goes home the same day. Participating physician Physician agrees to accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of the approved charges) after the $100 deductible has been met. Payer of last resort The principle that Medicaid pays last on a claim when a patient has other insurance coverage in place. Peer review The determination of a medical insurance payment or resolution of a claim dispute between a carrier and a physician by a group of independent physicians, Physician's profile Also known as fee profile. Compilation of a physician's charges and payment made through the years for each professional service rendered to a patient. As charges are increased, so are payments and the profile is then updated through the use of computer data. Policyholder A person who buys an insurance plan; the insured, subscriber, or guarantor. Preauthorization Determination off whether or not a particular treatment is medically necessary and covered by the insurance policy; required by many insurance companies Precertification Determination of whether or not a particular treatment is covered by the insurance policy; required by many insurance companies Predetermination Determination of the potential dollar amount the insurance company will pay for a particular treatment. Preexisting condition An illness or disorder of a beneficiary that existed before the effective date of insurance coverage. Premium The periodic amount of money the insured pays to a health plan for a health care policy. Preferred provider organization A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge. Primary care physician A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper. Primary diagnosis The condition considered to be the major health problem for the patient for the submitted claim. Primary payer Term used to describe which health insurance policy will pay "first" when an individual is covered by more than one health insurance policy. Provider A person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home. Referral Transfer of patient care from one physician to another. Reimbursement Receiving payment for services rendered. Relative value scale A system of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them. Release of Information A statement that permits the provider to give the carrier information needed to help process the claim. Secondary Payer Term used to describe which health insurance policy will pay "second" when an individual is covered by more than one health insurance policy Third-party payer A private or governmental organization that insures or pays for health care on the behalf of beneficiaries. The insured person is the first party, the provider the second party, and the payer the third party. In Medicaid and Worker's Compensation claims the patient is not the first party. Third party subrogation The legal process by which an insurance company seeks from a third party who has caused a loss, recovery of the amount paid to the policyholder. Time limit Number of days allowed to submit a claim (request for payment) Urgent care Medically necessary treatment that is required for illness or injury that would result in further disability or death if not treated immediately. Usual, customary, and reasonable In indemnity plans, an amount paid for health care services by an insurance carrier based on a combination of the usual fee the individual physician charges for the service, the customary fee charged by most physicians in the community, and the reasonable fee based on the appropriateness of the charge considering the circumstances. Usual fee The fee normally charged for a given professional service by an individual physician to patients. Customary fee The fee that is in the range of usual fees charged by physicians of similar training and experience for the same services within the same specific and limited socioeconomic area. Reasonable fee The fee that meets the two criteria above or is considered justifiable by responsible medical opinion, considering the special circumstance of the particular case in question Write off To discount a patient's fee in accordance with contractual agreements