Medical Insurance Chapter 10

advance beneficiary notice of noncoverage (ABN)
Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program
Health plan; also known as insurance company, payer, or third-party payer.
Clinical Labratory Improvement Amendments (CLIA)
Federal law establishing standards for laboratory testing performed in hospital-based facilities,physicians' office laboratories, and other locations;administered by CMS.
Common Working File (CWF)
Medicare's master patient/procedural database.
fiscal intermediary
Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims.
Health Professional Shortage Area (HPSA)
Medicare-defined geographical area offering participation bonuses to physicians.
incident to
Term for services of allied health professionals, such as nurses, technicians, and therapists, provided under the physician's direct supervision that may be billed under Medicare.
initial preventive physical examination (IPPE)
Medicare benefit of a preventive visit for new beneficiaries.
limiting charge
In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service.
local coverage determination (LCD)
Notices sent to physicians that contain detailed and updated information about the coding and medical necessity of a specific Medicare service.
Medical Review (MR) Program
A payer's procedures for ensuring that providers give patients the most appropriate care in the most cost-effective manner.
Medical Savings Account (MSA)
The Medicare health savings account program.
Medicare advantage
Medicare plans other than the Original Medicare Plan.
Medicare card
Insurance identification card issued to Medicare beneficiaries.
Medicare health insurance claim number (HICN)
Medicare beneficiary's identification number; appears on the Medicare card.
Medicare Modernization Act (MMA)
Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which included a prescription drug benefit.
Medicare Part A (Hospital Insurance [HI])
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B (Supplementary Medical Insurance [SMI])
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Medicare Part C
Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program.
Medicare Part D
Prescription drug reimbursement plans offered to Medicare beneficiaries.
Medicare Summary Notice (MSN)
Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined.
Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage.
national coverage determination (NCD)
Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.
Original Medicare Plan
The Medicare fee-for-service plan.
Quality Improvement Organization (QIO)
State-based group of physicians who are paid by the government to review aspects of the Medicare program, including the quality and appropriateness of services provided and fees charged.
Physician Quality Reporting Initiative (PQRI)
a CMS program that provides a potential bonus for performance by physicians on selected measures addressing quality of care
recovery audit contractor (RAC)
a program that aims to validate claims that have been paid to providers + to collect a payback of any incorrect payments that are identified
roster billing
Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines.
screening service
Tests or procedures performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease; used to detect an undiagnosed disease so that medical treatment can begin.
urgently needed care
In Medicare, a beneficiary's unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan's service area.
waived tests
Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices.