How the decision was made regarding the payment of an insurance claim.
Advance Beneficiary notice (ABN)
A form that Medicare requires all healthcare providers to use when Medicare does not pay for a service. Patients must sign the form to acknowledge that they understand they have a choice about their healthcare in the event that Medicare does not pay.
The fees Medicare allows for a particular service or supply.
An individual who has health insurance through the Medicare, Medicaid, or TRICARE programs.
The duration of time during which a Medicare beneficiary is eligible for Part A benefits for services incurred in a hospital or a skilled nursing facility (SNF) or both. A benefit period begins the day an individual is admitted to a hospital or and SNF and ends when the beneficiary has not received care in a hospital or SNF for 60 consecutive days.
Claims adjustment reason codes
Codes that detail the reason why an adjustment was made to a healthcare claim payment by the payer. Used in the electronic remittance advice and the standard paper remittance advice.
Coordination of benefits contractor
An individual who ensures that the information on Medicare's eligibility database regarding other health insurance primary to Medicare is up-to-date and accurate.
The basic benefits offered by the Medicare Part D Prescription Drug Plan. A Medicare beneficiary who does not choose to enroll in a Part D Plan must acquire a "certificate of credible coverage" to avoid a penalty if he or she decides to sign up after the open-enrollment period.
The process of matching one set of data elements or category codes to their equivalents within a new set of elements or codes.
Under Medicare rules, a beneficiary, on receiving notification of noncoverage, has the right to request that a fiscal intermediary review that determination.
When claims are submitted with outdated, deleted, or nonexsistent CPT codes, and the payer assigns a substitute code it thinks best fits the services preformed, resulting in a decreased payment. Also, down coding can result when Evaluation and Management levels do not match up with diagnostic codes.
Patients who are eligible for Medicaid and Medicare coverage.
Electronic Medicare Summary Notice (MSN)-
A quick and convenient way for beneficiaries to track their claims that allows beneficiaries to look at their Medicare Summary Notice on the Web and print copies from their home computers.
Electronic Remittance Advice (ERA)
One of several different types of electronic format rather than a paper document. Payments can be posted automatically to patient accounts, allowing the health insurance professional to update accounts receivable much more quickly than if he or she had to post the payments manually.
Health Insurance Claim Number (HICN)
A number assigned to a Medicare beneficiary that allows the health insurance professional to look at the patient's id card and immediately determine the level of coverage. The number is in the format of 9 digits, usually the beneficiary's Social Security number, followed by one alpha character.
Claims submitted for reimbursement under Medicare including claims with paper attachments, demand bills, claims where Medicare is the secondary payer and there is only one primary payer, claims submitted to a Medicare fee-for-service carrier or FI for the first time including resubmitted previously rejected claims, and nonpayment claims.
Mandated Medigap Transfer
A claim for which a beneficiary elects to assign his or her benefits under a Medigap policy to a participating physician/supplier.
A comprehensive federal insurance program established by Congress in 1966 that provides financial assistance with medical expenses to individuals 65 years or older and individuals younger than 65 with certain disabilities.
Consists of a network of physicians and other healthcare providers. Members/enrollees must receive care only from the providers in the network except in emergencies. The least expensive and most restrictive Medicare managed care plan.
Medicare Nonparticipating Provider (nonPAR)
Provider or supplier who has not signed a contract with Medicare and may choose whether or not to accept Medicare's approved amount as payment on a case-by-case basis. If they do not accept the approved amount, the beneficiary pays the full billed amount.
Medicare Participating Provider (PAR)
Provider or supplies who has signed a contract with Medicare and agrees to accept Medicare's allowed amount as payment in full.
Medicare Part A
Hospital insurance. Helps pay for medically necessary services, including inpatient hospital care, inpatient care in a skilled nursing facility, home healthcare and hospice care.
Medicare Part A fiscal intermediary (FI)
Private organization that contracts with Medicare Part A and some Part B bills. Determines payment to Part A facilities for covered items and services provided by the facility.
Medicare Part B
Medical (physicians' care) insurance financed by a combination of federal government funds and beneficiary premiums.
Medicare Part C (Medicare Advantage Plans)
Prepaid healthcare plans that offer regular Part A and Part B Medicare coverage in addition to coverage for other services. Formerly called Medicare+Choice.
Medicare Part D (Prescriptions Drug Plan)
Pays a portion of prescription drug expenses and cost sharing for qualifying individuals.
Medicare Summary Notice (MSN)-
A monthly statement that the beneficiary receives from Medicare after a claim is filed. The statement lists Part A and Part B claims information, including the patient's deductible.
Situations in which an item or service is not covered under Medicare.
Open Enrollment Period
A 6-month period when an individual may sign up for Medicare and Medigap policies, or both.
Program of All-inclusive Care for the Elderly (PACE)-
A program that provides comprehensive alternative care for noninstitutionalized elderly individuals, 55 years and older, who would otherwise be in a nursing home. A multidisciplinary team composed of a physician, nurse, therapists, dietician, social worker; home care coordinator and transportation supervisor completes an initial and semiannual assessment of each participant with a documented plan of treatment.
Provider-sponsored Organization (PSO)
Group of medical providers- physicians, clinics, and hospitals- that skip the insurance company middle man and contracts directly with patients. Members pay a premium and a copayment each time a service is rendered,
Quality Review Study
An assessment of patient care designed to achieve measurable improvement in processes and outcomes of care. Improvements are achieved through interventions that target healthcare providers, practitioners, plans or beneficiaries.
Remittance Remark codes
Codes that represent nonfinancial information on a Medicare remittance advice.
When a member of a managed healthcare group is allowed to receive services from specialists without first going through a primary care physician.
Trading Partner Agreement
A formal contract between Medicare Part B and a supplemental insurer.
In Medicare Part D, once the initial coverage limit is reached, beneficiaries are subject to another deductible, know officially as the "Coverage Gap". In which they must pay the full cost of the medicine.