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How the decision was made regarding the payment of an insurance claim.

Advanced Beneficiary Notice (ABN)

the form signed by the patient to instruct the health care providers on which life saving procedures the patient wishes to have

Allowable Charges

fees that Medicare permits for a particular service or supply


An individual who has health insurance through Medicare, Medicaid or Tricare programs.

Benefit Period

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


Drugs or medicinal preparations obtained from animal tissue or other organic sources.

Claim Adjustment Reason Codes

Codes that detail the reasons why and adjustment was made to a healthcare claim payment to a provider. Used in electronic remittance advice.

Clinical Laboratory Improvement Act

CLIA, Program Congress established in 1988 to regulate quality standards for all laboratory testing on humans to insure the safety, accuracy, reliabilty amd timelines of patient test results regardless of where the test were performed.

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.

Coverage Requirements

it must be considered medically necessary- reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part

Credible Coverage

The basic benefits offered by the Medicare Part D Prescription Drug Plan.


the process of matching one set of data elements or catergory of codes to their equivalents within a new set of elements ot codes

Demand Bills

a beneficary, on receiving notification of noncoverage, has the right to request that a fiscal intermediary review that determination

Denial Notice

An explanation that a local coverage decision does not cover a certain item or service


occurs when the coding system used on a claim does not match that used by the insurance company recieving the claim

Dual Eligibles

Patients who are eligible for Medicaid and Medicare coverage.

Electronic Fund Transfer (EFT)

system that transfers cash by electronic communication rather than by paper documents

Electronic Medicare Summary Notice

A quick and convenient way for beneficiaries to track their claims that allows beneficiaries to look at their MSn on the Web and print copies.

Electronic Remittance Advice (ERA)

A document electronically transmitted to the hospital to provide an explanation of payment determination for a claim.

End Stage Renal Disease

a severe stage of chronic renal failure that requires life-sustaining treatment with either dialysis or a kidney transplant. BUN may be as high as 150 to 250 mg/dL.

Federal Insurance Contribution Act

Act that provides the federal system of old-age, survivors, disability and insurance.

Health Care Quality Improvement Act

Program created to improve health outcomes of all Medicare beneficiaries regardless of personal charecteristics, physical location or settings..

Health Insurance Claim Number (HICN)

Number assigned to Medicare beneficiary that allows the health insurance professional to look at a patients ID card & immediatley determine the levels of coveraage. Number is in the format of 9 digits usually SS# and one alpha code.

HMO with POS options

A health maintenance organization (HMO) member is allowed to see providers who are not in the HMO network and receive services from specialists without first going through a primary care physician; however, the plan pays a smaller portion of the bill than if the member had followed regular HMO procedures. The member also pays a higher premium and a higher copayment each time the option is used.

Initial Claim

Claims submitted for reimbursement under Medicare, Including paper claims, demand nills, claims where Midicare is secondary payer and there is only one primary.

Lifetime release of information

A form that a beneficiary may sign authorizing a life-time release of information, instead of signing a form annually.

Local coverage determinations (LCD)

Pure medical necessity documents that focus exclusively on whether a service is reasonable and necessary according to the ICD-9-CM code for that particular CPT procedure code.

Local medical review policies (LMRP)

Policies that outline general provisions for the acceptance or rejection of Medicare claims.

Mandated Medigap Transfer

a claim for which a beneficiary elects to assign his or her benefits under a Medigap policy to a PAR

Medically Necessary

Medical services, procedures, or supplies that are reasonable and necessary for the diagnosis or treatment of a patient's medical condition, in accordance with the standards of good medical practice, performed at the proper level, and provided in the most appropriate setting.


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.

Medicare Beneficiary Protection Program

A Medicare quality-improvement organization that helps protect the safety and health of Medicare beneficiaries through numerous activities, such as responses to beneficiary complaints.

Medicare Gaps

The uninsured areas under Medicare with which elderly and disabled Americans need additional help.

Medicare HMO's

maintain a network of physicians and other healthcare providers; must recive care only from the providers in the network except in emergencies

Medicare Limiting Charges

15% of allowable charges over Medicare's approved amount. The limiting charges applies only to certain services and does not apply to supplies and equipment

Medicare Managed Care Plan

an HMO or PPO that uses Medicare to pay for part of its services for eligible beneficiaries

Medicare nonPAR

nonparticipating provider without a contractual agreement with insurance carrier to render care to eligible beneficiaries and bill the 3rd party directly. May or may not file claim as a courtesy; may obtain full payment at time of service

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 A Fiscal Intermediary

A private organization that contracts with Medicare to pay Part A.

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.

Medical Part B Carrier

Private Company that contracts with centers for Medicare and Medicade services to provide claims processing and payments.

Medicare Part B Crossover Program

a fee-per-claim service that Medicare Part B offers to private insurers and retirement plans

Medicare Part C

Managed Healthcare plans that offer regular Part A and Part B Medicare coverage and additional coverage for certain other services are called:

Medicare Part D

The prescription drug coverage plan, which began in January 2006, is called:

Medicare Participating Provider

PAR, Provider or suppliers who has contracted with Medicare & aggrees to accept Medicare;s allowed amount as payment in full

Medicare Secondary Payer

The term used when Medicare is not responsible for paying first when the beneficiary is covered under another insurance policy.

Medigap Insurance

An insurance plan offered by a federally approved private insurance carrier designed to supplement Medicare coverage.


Individuals who qulify for benefits under Medicare or Medcaid Programs

Noncovered Services

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 or Medigap policies. Also known as the pegboard system.

Peer Review Organization

group of medical reviewers contracted by the Centers for Medicare and Medicaid Services to ensure quality control and medical necessity of services provided by a facility. User-contributed

Program of all Inclusive Care for the Elderly

PACE, Provides comprehensive alternative care for noninstitutionalized elderly individuals, 55 yrs an older who would have otherwise been in a nursing home.

Provider Sponsored Organization, PSO

A group of medical providers that skips the insurance company middleman and contracts directly with patients

Quality Improvement Organization

a program that works with consumers, physicians, hospitlas, and other caregivers to refine care delivery systems to ensuure patients get the right care at the right time

Quality Review Study

an assessment of a patient care problem for the purpose of improving patient care hrough peer analysis, intervention, resolution of the problem, and follow-up

Remittance Remark Codes

Codes that represent non financial information on a Medicare remittance advice

Resource Based Relative Value System

RBRVS, Reimbursement system designed to address the increasing cost of healthcare in the US and try to resolve the inequities between geographical areas, time in practice and the current payment schedule. Replaces the Medicare fee system

Self Referring

some medicare hmo enrollees are allowed to see specialists outside the network without going throug a pci

Standard Paper Remittance Advice

SPRA, The product of a standarization of a provider payment notification of the center for Medicare & Medicaid Services.

Trading Partner Agreement

A formal contract between medicare Part B and a supplemental insurer

Prospective payment system (PPS)

Medicare's reimbursement system for inpatient hospital costs based on predetermined factors and not on individual services. Rates are set at a level intended to cover operating costs for treating a typical inpatient in a given diagnosis-related group. Payments for each hospital are adjusted for various factors, such as differences in area wages, teaching activity, and care to the poor.


An interrelated system of people and facilities that communicate with one another and work together as a unit. An approved list of physicians, hospitals, and other providers.

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 status.

Medicare Supplement Policy

A health insurance plan sold by private insurance companies to help pay for healthcare expenses not covered by Medicare and its deductibles and coinsurance

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