Principles in Healthcare Reimbursement Ch 3

Terms in this set (45)

Assignment of benefits

authorization by policyholder that allows a health plan to pay benefits directly to a provider

the portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage

An amount of money that an insured person must pay annually before health services are covered by the insurance plan

Electronic claims

Paperless claims (a.k.a. electronic media claims)

Explanation of benefits

a document from a payer sent to a patient that shows how the amount of benefit was deteremined

Health care claim

an electronic transaction or a paper document filed with a health plan to receive benefits

insurance company's agreement to reimburse a policy holder a predetermined amount for covered losses

Insurance carrier

health plan; also known as insurance company, payer, or third-party payer

Medical insurance

a financial plan that covers the cost of hospital and medical care due to illness or injury

Medically necessary

payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice. The reported procedure or service (1) matches the diagnosis, (2) is not elective (3) is not experimental, (4) has not been performed for the convenience of the patient or the patient's family; and (5) has been provided at the appropriate level

A person who buys an insurance plan; the insured, subscriber, or guarantor.

Preexisting condition

An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.

Remittance advice

health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits

Document signed by a patient that permits release of particular medical information under the specific states conditions.

Compliance plan

A medical practice's written plan for (a) the appointment of a compliance officer and committee, (b) a code of conduct for physicians' business arrangements and employees' compliance, (c) training plans, (d) properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates, (e) rules for prompt identification and refunding of overpayments, and (f) ongoing monitoring and auditing of claim preparation.

Nation Provider Identifier

Under HIPAA, unique 10 digit identifier assigned to each provider by the National Provider System; replaces both the UPIN and Medicare PIN

Calculated based on classification schemes such as diagnosis related groups

The number assigned to a diagnosis in the International Classification of Diseases

Abbreviated title of International Classification of Diseases, 9th revision, Clinical modification.

Primary diagnosis

a diagnosis that represents the patient's major illness or condition for an encounter

Consumer-driven health plan

Type of medical insurance that combine a high deductible health plan with a medical savings plan which covers some out of pocket expenses.

A fixed, periodic amount that must be met by the combination of payments for covered services to each individual of an insured/dependent group before benefits from a payer begin.

False Claims Act

Legislation passed during the Civil War that prohibits contractors from making a false claim to a governmental program; used to reinforce the prevention of healthcare fraud and abuse

Allowable charge

Average or maximum amount a third party payer will reimburse providers for a service

Electronic data interchange

The exchange (system to system) of data in a standardized format.

Secondary insurance

the health plan that pays benefits after the primary plan when a patient is covered by more than one plan

Health insurance was "born" in the Texas in 1929 with this plan

Advance beneficiary notice

Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.

Secondary payer

Term used to describe which health insurance policy will pay "second" when an individual is covered by more than one health insurance policy

a federal and state assistance program that pays for health care services for people who cannot afford them

Medically indigent

medically needy

a government program that provides cash assitance for low-income families Temporary Assistance for Needy Families

Welfare reform act

1996 law that established the Temporary Assistance for Needy Families program in place of the Aid to Families with Dependent Children program and tightened Medicaid eligibility requirements

The Civilian Health and Medical Program of the Veterans Administration (now known as the Department of Veterans Affairs) which shares health care costs for families of veterans with 100 percent service-connected disability and the surviving spouses and children of veterans who die from service-connected disabilities.

A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.

Defense Enrollment Eligibility Reporting System

The office of the U.S. Department of Labor that administers the Federal Employee's Compensation Act

Costs include the deductible, cost-sharing arising from the operation of the coinsurance clause, and medical expenditures

Civil Service Retirement System

The federal law that authorizes payroll deductions for the Social Security Disability Program

the federal disability compensation program for salaried and hourly wage earners, self-employed people who pay a special tax, and widows, widowers, and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefits if alive Social Security Disability Insurance

a government program that helps pay living expenses for low-income older people and those who are blind or have disabilities Social Security Income

Balanced Budget Act of 1997

Legislation intended to reduce Medicare spending, create incentives for development of managed care plans, encourage enrollment in managed care plans, and limit fee-for-service payment and programs

Coordination of Benefits

Health insurance policy clause that applies to an individual covered by more than one medical insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.

Principal diagnosis

A condition that after study is established as chiefly responsible for a patient's admission to a hospital

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