Reimbursement Terminology

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Advance Beneficiary Notice

ABN, notification in advance of services that medicare probably will not pay for and the estimated cost to patient (formerly WOL, waiver of liability)

Ancillary service

A service that is supportive of care of a patient, such as laboratory services

Assignment

a legal agreement that allows the provider to receive direct payment from a payer and the provider to accept payment as payment in full for covered services

Attending Physician

The physician legally responsible for oversight of an inpatients care (in residency programs, the teaching physician that monitors the resident's work)

beneficiary

The person who benefits from insurance coverage; also known as subscriber, dependent, enrolle, member, or participant

Birthday Rule

When both parents have insurance coverage, the parent with the birthday earlier in the year carries the primary coverage for a dependent

Certified registered nurse anesthetist

CRNA, an individual with specialized training and certification in nursing and anesthesia

"clean claim"

a properly completed CMS-1500 form submitted to a payer with all data boxes containing current and accurate information and submitted within the timely filing period required by the insurer

coinsurance

cost-sharing of covered services

compliance plan

written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with third-party payer guidelines and the office of the inspector general (OIG) workplan guidelines

concurrent care

more than one physician providing care to a patient at the same time

coordination of benefits

COB, management of multiple third-party payments to ensure overpayment does not occur

co-payment

cost-sharing between beneficiary and payer

deductible

that portion of covered services paid by the beneficiary before third-party payment begins

denial

statement from a payer that coverage is denied

documentation

detailed chronology of facts and observations, procedures, services, and diagnoses relative to the patients health

durable medical equipment

DME, medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers

electronic data interchange

EDI, computerized submission of health care insurance information exchange

Employer Identification Number

EIN, an internal revenue services (IRS)- issued identification number used on tax documents

encounter form superbill

medical document that contains information regarding a patient visit for health care services, can serve as a billing and/or coding document

explanation of benefits

EOB or EOMB, written, detailed listing of medical service payments by third-party payer to inform beneficiary and provider of payment

Fee schedule

List of established payment for medical services arranged by CPT and HCPCS codes

Follow-up Days

FUD, established by third-party payers and listing the number of days after a procedure for which a provider must provide services to a patient for no fee. Also known s global days, global package, and global period

group provider number

GPN, a numeric designation for a group of providers that is used instead of the individual provider number

HMO

health maintenance organization

invalid claim

claim that is missing necessary information and cannot be processed or paid

medical record

documentation about the health care of a patient to include diagnoses, services, and procedures rendered

noncovered services

any service not included by a third-party payer in the list of services for which payment is made

national provider identifier

NPI, 10-digit number assigned to a provider by CMS and national plan and provider enumeration system (NPPES) and used for identification purposes when submitting services to third-party payers

point of service

POS, a plan in which either an in-network or out-of-network provider may be used with a higher rate paid to in-network providers

preferred provider organization

PPO, providers form a network to offer health care services to a group

prior authorization

also known as preauthorization, which is a requirement by the payer to receive written permission prior to patient services in order to be considered for payment by the payer

provider identification number

PIN, a number assigned by a third-party payer to providers to be used for identification purposes when submitting claims

reimbursement

payment from a thrid-party payer for services rendered to a patient covered by the payer's health care plan

rejection/denial

a claim that did not pass the edits and is returned to the provider as rejected

resource-based relative value scale

RBRVS, is a list of physicians with assigned units of monetary value

state license number

identification number issued by a state to a physician who has been granted the right to practice in that state

UPIN

unique provider identification number was replaced by the NPI

Usual, customary, and reasonable

UCR, used by some third-party payers to establish a payment rate for a service in an area with the usual (standard fee in area), customary (standard fee by the physician), and reasonable (as determined by payer) fee amounts

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