Mod 160 Unit 2
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50 terms
Terms | Definitions |
|---|---|
 Advanced Beneficiary Notice(ABN) | an agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment because of medical necessity or limitation of liability by medicare |
| Approved Charges | a fee that medicare decides the medical service is worth, which may or may not be the same as the actual amount billed |
| Assignment | a transfer after an event insured against or an individuals legal right to collect an amount payable under an insurance contract |
| Benefit Period | a period of time during which payments for medicare inpatient hospital benefits are available |
| Centers for Medicare and Medicaid Services(CMS) | formerly known as the health care financing administration CMS divides responsibilities among three divisions |
| Crossover claim | a bill for services rendered to a patient receiving benefits simultaneously from medicare and medicaid or from medicare and a medigap plan |
| Diagnostic cost groups(DCG) | a system of medicare reimbursement for HMOs with risk contracts in which enrollees are classified into various DCGs on the basis of each beneficiary's prior 12 month hospitalization history |
| Disabled | for purposes of of enrollment under medicare, individuals younger than 65 years of age who have been entitled to disability benefits under the social security act or the railroad retirement system for at least 24 months are considered disabled and are entitled to medicare |
| End stage renal disease(ESRD) | individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. |
| Fiscal Intermediary(FI) | for TRICARE and CHAMPVA, the insurance company that handles the claims for care received within a particular state or country |
| Hospice | a public agency or private organization primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill patients and their families in their own homes or in a homelike center |
| hospital insurance | aka medicare part A. a program providing basic protection against the cost of hospital and related after-hospital services for individuals eligible under the medicare program |
| intermediate care facility | institutions furnishing health related care and services to individuals who do not require the degree of care provided by acute care hospitals or nursing facilities |
| limiting charge | a percentage limit on fees, specified by legislations, that nonparticipating physicians may bill medicare beneficiaries above the fee schedule amount. |
| medical necessity | the performance of services and procedures that are consistent. |
| medicare | A nationwide health insurance program for persons age 65 years of age and older and certain disabled or blind persons regardless of income, administrated by HCFA. |
| medicare A | Hospital benefits of a nationwide health insurance program for persons 65 years of age and older and certain disabled individuals regardless of income, administered by CMS. |
| medicare B | Medical insurance of a nationwide health insurance program for persons age 65 years of age and older and certain disabled individuals regardless of income, administered by CMS. |
| Medicare C | Medicare plus(+) choice plans offer a number of health care options in addition to those available under Medicare part A and part B. |
| medicare D | stand- alone prescription drug plan,presented by insurance and other private companies that offer drug coverage that meets the standards established by Medicare. |
| medicare/medicaid(medi-medi) | Refers to an individual who receives medical or disability benefits from both Medicare or Medicaid programs. |
| medicare secondary payer | The primary insurance plan of a Medicare beneficiary that must pay for any medical care services first before Medicare is sent a claim. |
| medicare summary notice(MSN) | A document received by the patient explaining amount charged, Medicare approved, deductible, and coinsurance for medical services rendered. |
| Medigap | A specialized supplemental insurance policy devised for the Medicare beneficiary that covers the deductible and copayment amounts typically not covered under the main medicare policy written by a nongovernment third-party payer. |
| National alphanumeric codes | Alphanumeric codes developed by HCFA. |
| Nonparticipating physician(nonpar) | A provider who does not have a signed agreement with Medicare and has an option about assignment. |
| Nursing Facility(NF) | A specially qualified facility that has the staff and equipment to provide skilled nursing care and related services that are medically necessary to a patient's recovery. |
| Participating physician(par) | A physician who agrees to accept payment from Medicare (80% of the approved charges) plus payment from the patient (20% of approved charges) after the $100 deductible has been met. |
| Premium | The cost of insurance coverage paid annually, semiannually, or monthly to keep the policy in force. |
| Prospective payment system(PPS) | A method of payment for Medicare hospital insurance based on diagnosis-related groups(DRGs) ( a fixed dollar amount for a principal diagnosis). |
| Qui tam action | An action to recover a penalty brought on by an informer in a situation in which one portion of the recovery goes to the informer and the other portion to the state or government. |
| Reasonable fee | A charge is considered reasonable if it is deemed acceptable after peer review even though it does not meet the customary or prevailing criteria. |
| Relative Value Unit(RVU) | a monetary value assigned to each service on the basis of the amount of physician work,practice expenses, and cost professional liability insurance. |
| Remittance Advice(RA) | A document detailed services billed describing payment determination issued to providers of the medicare or medicaid program. |
| Supplemental security income(SSI) | A program of income support for low-income aged, blind, and disabled persons established by Title XVI of the Social Security Act. |
| Supplementary medical insurance(SMI) | Part B- medical benefits of Medicare program. |
| Volume performance standard(VPS) | The desired growth rate for spending on Medicare Part B physician services, set each year by Congress. |
| -Ism | Condition |
| -Orexia | Appetite |
| -Ary | Pertaining to |
| Colon | Colon |
| Chol/e | Gall, Bile |
| Dys- | Bad, Difficult, Painful, Abnormal |
| Gastr | Stomach |
| -Stomy | New opening |
| Dysentery | An intestinal disease characterized by inflammation of the mucous membrane. |
| Hiatal Hernia | Occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm. |
| Rectocele | Hernia of part of the rectum into the vagina. |
| Gavage | To feed liquid or semiliquid food via a tube (stomach or nasogastric). |
| Lavage | To wash out a cavity. Gastric lavage is used to remove or dilute gastric contents in case of acute poisoning or ingestion of a caustic substance. |
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