39 terms

Reimbursement Terminology

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
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)
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
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
cost-sharing between beneficiary and payer
that portion of covered services paid by the beneficiary before third-party payment begins
statement from a payer that coverage is denied
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
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
payment from a thrid-party payer for services rendered to a patient covered by the payer's health care plan
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
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