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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
Coinsurance
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
Deductible
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
Indemnity plan
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
Policyholder
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
Authorization
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
Case Mix Index
Calculated based on classification schemes such as diagnosis related groups
Diagnosis code
The number assigned to a diagnosis in the International Classification of Diseases
ICD-9-CM
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.
Deductible
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
Blue Cross
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
Medicaid
a federal and state assistance program that pays for health care services for people who cannot afford them
Medically indigent
medically needy
TANF
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
CHAMPVA
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.
TRICARE
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.
DEERS
Defense Enrollment Eligibility Reporting System
OWCP
The office of the U.S. Department of Labor that administers the Federal Employee's Compensation Act
Out-of pocket
Costs include the deductible, cost-sharing arising from the operation of the coinsurance clause, and medical expenditures
CSRS
Civil Service Retirement System
FICA
The federal law that authorizes payroll deductions for the Social Security Disability Program
SSDI
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
SSI
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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