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abuse  Actions that improperly use another person's resources.
accept assignment (acceptance of assignment)  A participating physician's agreement to accept the allowed charge as payment in full.
access  The ability or means necessary to read, write, modify, or communicate information or otherwise use a system resource.
accounts receivable (A/R)  Monies owed to a medical practice by its patients and third-party payers.
Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)  The ANSI-accredited standards development organization that maintains the administrative and financial electronic transactions standards adopted under HIPAA.
Acknowledgment of Receipt of Notice of Privacy Practices  Form accompanying a covered entity's Notice of Privacy Practices; covered entities must make a good-faith effort to have patients sign the acknowledgment.
acute  Describes an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.
addenda  Updates to the ICD-9-CM diagnostic coding system.
Additional Documentation Request  Carrier request for information during a Medicare Medical Review.
add-on code  Procedure that is performed and reported only in addition to a primary procedure; indicated in CPT by a plus sign (+).
adjudication  The process followed by health plans to examine claims and determine benefits.
adjustment  An amount (positive or negative) entered in a patient billing program to change a patient's account balance.
administrative code set  Under HIPAA, required codes for various data elements, such as taxonomy codes and place of service (POS) codes.
administrative services only (ASO)  Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.
Admission of Liability  Carrier's determination that an employer is responsible for an employee's claim under workers' compensation.
admitting diagnosis (ADX)  The patient's condition determined by a physician at admission to an inpatient facility.
advance beneficiary notice (ABN)  Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
adverse effect  Condition caused by a drug that has been used correctly.
advisory opinion  An opinion issued by CMS or the OIG that becomes legal advice for the requesting party; a requesting party who acts according to the advice is immune from investigation on the matter; the advisory opinion provides guidance for others in similar matters.
aging  Classification of accounts receivable by the length of time an account is due.
allowed charge  The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Alphabetic Index  The section of the ICD-9-CM in which diseases and injuries with corresponding diagnosis codes are presented in alphabetical order.
ambulatory care  Outpatient care.
ambulatory patient classification (APC)  A Medicare payment classification for outpatient services.
ambulatory surgical center (ASC)  A clinic that provides outpatient surgery.
ambulatory surgical unit (ASU)  A hospital department that provides outpatient surgery.
American Academy of Professional Coders (AAPC)  National association that fosters the establishment and maintenance of professional, ethical, educational, and certification standards for medical coding.
American Association of Medical Assistants  National association that fosters the profession of medical assisting.
American Association for Medical Transcription  National association fostering the profession of medical transcription.
American Health Information Management Association (AHIMA)  National association of health information management professionals that promotes valid, accessible, yet confidential health information and advocates quality health care.
American Medical Association (AMA)  Member organization for physicians that aims to promote the art and science of medicine, improve public health, and promote ethical, educational, and clinical standards for the medical profession.
American National Standards Institute (ANSI)  Organization that sets standards for electronic data interchange on a national level.
ancillary services  Supplemental medical services such as diagnostic services and occupational therapy that support the diagnosis and treatment of patients' conditions.
appeal  A request sent to a payer for reconsideration of a claim adjudication.
appellant  One who appeals a claim decision.
assignment of benefits  Authorization by a policyholder that allows a health plan to pay benefits directly to a provider.
assumption coding  Reporting undocumented services that the coder assumes have been provided because of the nature of the case or condition.
at-home recovery care  Assistance with the activities of daily living provided for a patient in the home.
attending physician  The clinician primarily responsible for the care of the patient from the beginning of a hospitalization.
audit  Methodical review; in medical insurance, a formal examination of a physician's accounting or patient medical records.
authorization  1) Document signed by a patient to permit release of particular medical information under the stated specific conditions. 2) A health plan's system of approving payment of benefits for services that satisfy the plan's requirements for coverage. See preauthorization.
autoposting  Software feature that enables automatic entry of payments on a remittance advice to credit an individual's account.
   

 

 

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bad debt  An account deemed uncollectible.
balance billing  Collecting the difference between a provider's usual fee and a payer's lower allowed charge from the insured.
bankruptcy  Legal declaration that a person is unable to pay his or her debts.
benefits  The amount of money a health plan pays for services covered in an insurance policy.
billing provider  The person or organization (often a clearinghouse or billing service) sending a HIPAA claim, as distinct from the pay-to provider who receives payment.
billing service  Company that provides billing and claim processing services.
birthday rule  The guideline that determines which of two parents with medical coverage has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary.
BlueCard  A Blue Cross and Blue Shield program that provides benefits for plan subscribers who are away from their local areas.
Blue Cross  A primarily nonprofit corporation that offers prepaid medical benefits for hospital services and some outpatient, home care, and other institutional services.
Blue Cross and Blue Shield Association (BCBS)  The national licensing agency of Blue Cross and Blue Shield plans.
Blue Shield  A primarily nonprofit corporation that offers prepaid medical benefits for physician, dental, and vision services and other outpatient care.
bundling  A single procedure code that covers a group of related procedures.
business associate  A person or organization that performs a function or activity for a covered entity but is not part of its workforce.
   

 

 

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capitation  Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
capitation rate (cap rate)  The contractually set periodic prepayment to a provider for specified services to each enrolled plan member.
carrier  Health plan; also known as insurance company, payer, or third-party payer.
carve out  A part of a standard health plan that is changed under a negotiated employer-sponsored plan; also refers to subcontracting of coverage by a health plan.
case mix index  A measure of the clinical severity or resource requirements of the patients in a particular hospital or treated by a particular clinician during a specific time period.
cash flow  The inflow of payments from patients and payers to a medical practice and the outflow from the practice of payments to suppliers and staff; based on the actual movement of money rather than amounts that are receivable or payable.
catastrophic cap  The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share.
catchment area  A geographic area usually within approximately forty miles of military inpatient treatment facilities; under TRICARE, the facility in a patient's area must issue a nonavailability statement before the patient can be treated at a nonmilitary facility.
categorically needy  A person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF).
category  In the ICD-9-CM, a three-digit code used to classify a particular disease or injury.
Category I codes  Procedure codes found in the main body of CPT (Evaluation and Management, Anesthesia, Surgery, Pathology and Laboratory, Radiology, and Medicine).
Category II codes  Optional CPT codes that track performance measures for a medical goal such as reducing tobacco use.
Category III codes  Temporary codes for emerging technology, services, and procedures that are used instead of unlisted codes when available.
CCI column 1/column 2 code pair edit  A Medicare code edit under which CPT codes in column 2 will not be paid if reported for the same patient on the same day of service by the same provider as the column 1 code.
CCI modifier indicator  A number that shows whether the use of a modifier can bypass a CCI edit.
CCI mutually exclusive code (MEC) edit  Under the CCI edits, both services represented by MEC codes could not have reasonably been done during a single patient encounter, so they will not both be paid by Medicare; only the lower-paid code is reimbursed.
Centers for Medicare and Medicaid Services (CMS)  Federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, clinical laboratories (under the CLIA program), and other government health programs.
certificate  Term for a Blue Cross and Blue Shield medical insurance policy.
certification number  Number returned electronically by a health plan when approving a referral authorization request.
CHAMPUS  Now the TRICARE program; formerly the Civilian Health and Medical Program of the Uniformed Services (Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration) that serves spouses and children of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members.
CHAMPVA  The Civilian Health and Medical Program of the Department of Veterans Affairs (previously know as the Veterans Administration) that shares health care costs for families of veterans with 100 percent service-connected disabilities and the surviving spouses and children of veterans who die from service-connected disabilities.
charge-based fee structure  Fees based on the amounts typically charged for similar services.
charge capture  Office procedures that ensure that billable services are recorded and reported for payment.
charge master  A hospital's list of the codes and charges for its services.
chart number  A unique number that identifies a patient.
chief complaint (CC)  A patient's description of the symptoms or other reasons for seeking medical care from a provider.
chronic  An illness or condition with a long duration.
Civilian Health and Medical Program of the Department of Veterans Affairs  See CHAMPVA.
claim adjustment group codes (GRP)  Codes used by a payer on an RA/EOB to indicate the general type of reason code for an adjustment.
claim adjustment reason code (RC)  Code used by a payer on an RA/EOB to explain why a payment does not match the amount billed.
claimant  Person or entity exercising the right to receive benefits.
claim attachment  Documentation that a provider sends to a payer in support of a health care claim.
claim control number  Unique number assigned to a health care claim by the sender.
claim filing indicator code  Administrative code used to identify the type of health plan.
claim frequency code (claim submission reasoncode)  Administrative code that identifies the claim as original, replacement, or void/cancel action.
claim scrubber  Software that checks claims to permit error correction for clean claims.
claim status category codes  Codes used by payers on a HIPAA 277 to report the status group for a claim, such as received or pending.
claim status codes  Codes used by payers on a HIPAA 277 to provide a detailed answer to a claim status inquiry.
claim turnaround time  The time period in which a health plan is obligated to process a claim.
clean claim  A claim that is accepted by a health plan for adjudication.
clearinghouse  A company (billing service, repricing company, or network) that converts nonstandard transactions into standard transactions and transmits the data to health plans; also handles the reverse process, changing standard transactions from health plans into nonstandard formats for providers.
Clinical Laboratory Improvement Amendments(CLIA)  Federal law establishing standards for laboratory testing performed in hospital-based facilities,physicians' office laboratories, and other locations;administered by CMS.
CMS  See Centers for Medicare and Medicaid Services.
CMS-1450  Paper claim for hospital services; also known as the UB-92.
CMS-1500  Paper claim for physician services.
CMS-1500 (08/05)  Current paper claim approved by the NUCC.
CMS HCPCS Workgroup  Federal government committee that maintains the Level II HCPCS code set.
code edits  Computerized screening system used to identify improperly or incorrectly reported codes.
code linkage  The connection between a service and a patient's condition or illness; establishes the medical necessity of the procedure.
code set  Alphabetic and/or numeric representations for data. Medical code sets are systems of medical terms that are required for HIPAA transactions. Administrative (nonmedical) code sets, such as taxonomy codes and ZIP codes, are also used in HIPAA transactions.
coding  The process of assigning numerical codes to diagnoses and procedures/services.
coexisting condition  Additional illness that either has an effect on the patient's primary illness or is also treated during the encounter.
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.
collection agency  Outside firm hired by a practice or facility to collect overdue accounts from patients.
collections  The process of following up on overdue accounts.
collections specialist  Administrative staff member with training in proper collections techniques.
combination code  A single code that classifies both the etiology and the manifestation of an illness or injury.
Common Working File (CWF)  Medicare's master patient/procedural database.
comorbidity  Admitted patient's coexisting condition that affects the length of the hospital stay or the course of treatment.
compliance  Actions that satisfy official guidelines and requirements.
compliance plan  A medical practice's written plan for the following: the appointment of a compliance officer and committee; a code of conduct for physicians' business arrangements and employees' compliance; training plans; properly prepared and updated coding tools such as job reference aids, encounter forms, and documentation templates; rules for prompt identification and refunding of overpayments; and ongoing monitoring and auditing of claim preparation.
complication  Condition an admitted patient develops after surgery or treatment that affects the length of hospital stay or the course of further treatment.
concurrent care  Medical situation in which a patient receives extensive, independent care from two or more attending physicians on the same date of service.
conditions of participation (Medicare) (COP)  Regulations concerning provider participation in the Medicare program.
Consolidated Omnibus Budget Reconciliation Act (COBRA)  Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the em-ployer's group health plan for eighteen months after termination.
consultation  Service performed by a physician to advise a requesting physician about a patient's condition and care; the consultant does not assume responsibility for the patient's care and must send a written report back to the requestor.
consumer-driven health plan (CDHP)  Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
contract  An enforceable voluntary agreement in which specific promises are made by one party in exchange for some consideration by the other party.
convention  Typographic techniques or standard practices that provide visual guidelines for understanding printed material.
conversion factor  Dollar amount used to multiply a relative value unit to arrive at a charge.
coordination of benefits (COB)  A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
copayment  An amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter.
corporate integrity agreement  A compliance action under which a provider's Medicare billing is monitored by the Office of the Inspector General.
Correct Coding Initiative (CCI)  Computerized Medicare system to prevent overpayment for procedures.
Correct Coding Initiative edits  Pairs of CPT or HCPCS Level II codes that are not separately payable by Medicare except under certain circumstances; the edits apply to services by the same provider for the same beneficiary on the same date of service.
cost share  Coinsurance for a TRICARE or CHAMPVA beneficiary.
Coverage Issues Manual (CIM)  Information about Medicare-qualified clinical trials, treatments, therapeutic interventions, diagnostic testing, durable medical equipment, therapies, and services referenced in the HCPCS code manual.
covered entity (CE)  Under HIPAA, a health plan, clearinghouse, or provider that transmits any health information in electronic form in connection with a HIPAA transaction; does not specifically include workers' compensation programs, property and casualty programs, or disability insurance programs.
covered services  Medical procedures and treatments that are included as benefits under an insured's health plan.
counseling  Physician's discussion with a patient and/or family about diagnostic results, prognosis, treatment options, and/or instructions.
CPT  Current Procedural Terminology, a publication of the American Medical Association.
credentialing  Periodic verification that a provider or facility meets the professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.
creditable coverage  History of health insurance coverage for calculation of COBRA benefits.
credit bureaus  Organizations that supply information about consumers' credit history and relative standing.
credit reporting  Analysis of a person's credit standing during the collections process.
crossover claim  Claim for a Medicare or Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer.
cross-reference  Directions in printed material that tell a reader where to look for additional information.
crosswalk  A comparison or map of the codes for the same or similar classifications under two coding systems; it serves as a guide for selecting the closest match.
Current Procedural Terminology (CPT)  Publication of the American Medical Association containing the HIPAA-mandated standardized classification system for reporting medical procedures and services performed by physicians.
cycle billing  Type of billing in which patients with current balances are divided into groups to even out statement printing and mailing throughout a month, rather than mailing all statements once a month.
   

 

 

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database  An organized collection of related data items having a specific structure.
data element  The smallest unit of information in a HIPAA transaction.
data format  An arrangement of electronic data for transmission.
date of service  The date of a patient encounter for medical services.
day sheet  In a medical office, a report that summarizes the business day's charges and payments, drawn from all the patient ledgers for the day.
deductible  An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
Defense Enrollment Eligibility Reporting System (DEERS)  The worldwide database of TRICARE and CHAMPVA beneficiaries.
de-identified health information  Medical data from which individual identifiers have been removed; also known as a redacted or blinded record.
dependent  A person other than the insured, such as a spouse or child, who is covered under a health plan.
descriptor  The narrative part of a CPT code that identifies the procedure or service.
designated record set (DRS)  A covered entity's records that contain protected health information (PHI); for providers, the designated record set is the medical/financial patient record.
destination payer  In HIPAA claims, the health plan receiving the claim.
determination  A payer's decision about the benefits due for a claim.
development  Payer process of gathering information in order to adjudicate a claim.
diagnosis  A physician's opinion of the nature of a patient's illness or injury.
diagnosis code  The number assigned to a diagnosis in the International Classification of Diseases.
diagnosis-related groups (DRG)  A system of analyzing conditions and treatments for similar groups of patients used to establish Medicare fees for hospital inpatient services.
diagnostic statement  A physician's description of the main reason for a patient's encounter; may also describe related conditions or symptoms.
direct provider  Clinician who treats the patient face-to-face, in contrast to an indirect provider such as a laboratory.
disability compensation program  A plan that reimburses the insured for lost income when the insured cannot work because of an illness or injury, whether or not it is work-related.
disallowed charge  An item on a remittance advice that identifies the difference between the allowable charge and the amount the physician charged for a service.
disclosure  The release, transfer, provision of, access to, or divulging in any other manner of information outside the entity that holds it.
discounted fee-for-service  A negotiated payment schedule for health care services based on a reduced percentage of a provider's usual charges.
documentation  The systematic, logical, and consistent recording of a patient's health status-history, examinations, tests, results of treatments, and observations- in chronological order in a patient medical record.
documentation template  Physician practice form used to prompt the physician to document a complete review of systems (ROS) when done and the medical necessity for the planned treatment.
domiciliary care  Care provided in the home; or providing care and living space, such as a home for disabled veterans.
downcoding  A payer's review and reduction of a procedure code (often an E/M code) to a lower level than reported by the provider.
dual-eligible  A Medicare-Medicaid beneficiary.
durable medical equipment (DME)  Medicare term for reusable physical supplies such as wheelchairs and hospital beds that are ordered by the provider for use in the home; reported with HCPCS Level II codes.
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)  Category of HCPCS services.
Durable Medical Equipment Regional Carrier (DMERC)  Medicare contractor that processes claims for durable medical equipment, prosthetics, orthotics, and supplies.
   

 

 

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Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)  Medicaid's prevention, early detection, and treatment program for eligible children under the age of twenty-one.
E code  Alphanumeric ICD code for an external cause of injury or poisoning.
edits  Computerized screening system used to identify improperly or incorrectly reported codes.
8371  HIPAA-mandated electronic transaction for hospital claims.
elective surgery  Nonemergency surgical procedure that can be scheduled in advance.
electronic claim  A health care claim that is transmitted electronically; also known as an electronic media claim (EMC).
electronic data interchange (EDI)  The system-to-system exchange of data in a standardized format.
electronic funds transfer (EFT)  Electronic routing of funds between banks.
electronic media  Electronic storage media, such as hard drives and removable media, and transmission media used to exchange information already in electronic storage media, such as the Internet. Paper transmission via fax and voice transmission via telephone are not electronic transmissions.
electronic medical record (EMR)  A running collection of health information that provides immediate electronic access by authorized users.
electronic remittance  Payment made through electronic funds transfer.
electronic remittance advice  See remittance advice.
E/M  See evaluation and management code.
emancipated minor  A person who has reached the legal age for an emancipated minor under state law.
embezzlement  Stealing of funds by an employee or contractor.
emergency  A situation in which a delay in the treatment of the patient would lead to a significant increase in the threat to life or body part.
Employee Retirement Income Security Act of 1974 (ERISA)  A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.
encounter  An office visit between a patient and a medical professional.
encounter form  A listing of the diagnoses, procedures, and charges for a patient's visit; also called the superbill.
encryption  A method of scrambling transmitted data so it cannot be deciphered without the use of a confidential process or key.
episode-of-care (EOC) option  A flat payment by a health plan to a provider for a defined set of services, such as care provided for a normal pregnancy, or for services for a certain period of time, such as a hospital stay.
eponym  A name or phrase that is formed from or based on a person's name; usually describes a condition or procedure associated with that person.
established patient  Patient who has received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
ethics  Standards of conduct based on moral principles.
etiology  The cause or origin of a disease.
etiquette  Standards of professional behavior.
evaluation and management (E/M) codes  Procedure codes that cover physicians' services performed to determine the optimum course for patient care; listed in the Evaluation and Management section of CPT.
excluded parties  Individuals or companies that, because of reasons bearing on professional competence, professional performance, or financial integrity, are not permitted by the OIG to participate in any federal health care programs.
excluded service  A service specified in a medical insurance contract as not covered.
explanation of benefits (EOB)  Document sent by a payer to a patient that shows how the amount of a benefit was determined.
explanation of Medicare benefits (EOMB)  See Medicare Summary Notice.
external audit  Audit conducted by an organization outside of the practice, such as a federal agency.
   

 

 

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Fair and Accurate Credit Transaction Act (FACTA)  Laws designed to modify the Fair Credit Reporting Act to protect the accuracy and privacy of credit reports.
Fair Credit Reporting Act (FCRA)  Law requiring consumer reporting agencies to have reasonable and fair procedures to protect both consumers and business users of the reports
Fair Debt Collection Practices Act of 1977 (FDCPA)  Laws regulating collection practices.
family deductible  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.
Federal Employee Compensation Act (FECA)  A federal law that provides workers' compensation insurance for civilian employees of the federal government.
Federal Employees Health Benefits Program (FEHBP)  The health insurance program that covers employees of the federal program.
Federal Employees Retirement System (FERS)  Disability program for employees of the federal government.
Federal Insurance Contribution Act (FICA)  The federal law that authorizes payroll deductions for the Social Security Disability Program.
Federal Medicaid Assistance Percentage (FMAP)  Basis for federal government Medicaid allocations to individual states.
fee-for-service  Method of charging under which a provider's payment is based on each service performed.
fee schedule  List of charges for services performed.
final report  A report filed by the physician in a state workers' compensation case when the patient is discharged.
financial policy  A practice's rules governing payment for medical services from patients.
firewall  A software system designed to block unauthorized entry to a computer's data.
first report of injury  A report filed in state workers' compensation cases that contains the employer's name and address, employee's supervisor, date and time of accident, geographic location of injury, and patient's description of what happened.
fiscal intermediary  Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims.
Flexible Blue  The Blue Cross and Blue Shield consumer-driven health plan.
flexible savings account (FSA)  Type of consumer-driven health funding plan option that has employer and employee contributions; funds left over revert to the employer.
formulary  A list of a health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists.
fragmented billing  Incorrect billing practice in which procedures covered under a single bundled code are unbundled and separately reported.
fraud  Intentional deceptive act to obtain a benefit.
   

 

 

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gatekeeper  See primary care physician.
gender rule  Coordination of benefits rule for a child insured under both parents' plans under which the father's insurance is primary
geographic practice cost index (GPCI)  Medicare factor used to adjust providers' fees to reflect the cost of providing services in a particular geographic area relative to national averages.
global period  The number of days surrounding a surgical procedure during which all services relating to the procedure-preoperative, during the surgery, and postoperative-are considered part of the surgical package and are not additionally reimbursed.
global surgical rule  See surgical package.
grievance  Right of a medical practice to file a complaint with the state insurance commission if it has been treated unfairly by a payer.
grouper  Software used to assign DRGs based on patients' diagnoses during hospitalization.
group health plan  Under HIPAA, a plan (including a self-insured plan) of an employer or employee organization to provide health care to the employees, former employees, or their families. Plans that are self-administered and have fewer than fifty participants are not group health plans.
guarantor  A person who is the insurance policyholder for a patient of the practice.
guarantor billing  Grouping patient billing under the insurance policyholder; the guarantor receives statements for all patients covered under the policy.
guardian  An adult legally responsible for care and custody of a minor.
   

 

 

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HCFA  See Centers for Medicare and Medicaid Services.
HCFA-1450  See CMS-1450.
HCFA-1500  See CMS-1500 (08/05).
Health and Human Services (HHS)  The U.S. Department of Health and Human Services, whose agencies have authority to create and enforce HIPAA regulations.
health care claim  An electronic transaction or a paper document filed with a health plan to receive benefits.
Healthcare Common Procedure Coding System (HCPCS)  Procedure codes for Medicare claims, made up of CPT codes (Level I) and national codes (Level II).
Health Care Financing Administration  See Centers for Medicare and Medicaid Services.
Health Care Fraud and Abuse Control Program  Government program to uncover misuse of funds in federal health care programs; run by the Office of the Inspector General.
Health Employer Data and Information Set (HEDIS)  Set of standard performance measures on the quality of a health care plan collected and disseminated by the National Committee for Quality Assurance (NCQA).
health information management (HIM)  Hospital department that organizes and maintains patient medical records; also profession devoted to managing, analyzing, and utilizing data vital for patient care, making the data accessible to health care providers.
Health Insurance Portability and Accountability Act (HIPAA) of 1996  Federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information.
health maintenance organization (HMO)  A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
health plan  Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans.
Health Professional Shortage Area (HPSA)  Medicare-defined geographical area offering participation bonuses to physicians.
health reimbursement account (HRA)  Type of consumer-driven health plan funding option under which an employer sets aside an annual amount an employee can use to pay for certain types of health care costs.
health savings account (HSA)  Type of consumer-drive health plan funding option under which employers, employees, both employers and employees, or individuals set aside funds that can be used to pay for certain types of health care costs.
high-deductible health plan (HDHP)  Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients' out-of-pocket expenses up to the deductible.
HIPAA claim  Generic term for the HIPAA X12N 837 professional health care claim transaction.
HIPAA Claim Status-Inquiry/Response  The HIPAA X12N 276/277 transaction in which a provider asks a health plan for information on a claim's status and receives an answer from the plan.
HIPAA Coordination of Benefits  The HIPAA ASCX12N 837 transaction that is sent to a secondary or tertiary payer on a claim with the primary payer's remittance advice.
HIPAA Electronic Health Care Transactions and Code Sets (TCS)  The HIPAA rule governing the electronic exchange of health information.
HIPAA Eligibility for a Health Plan  The HIPAA X12N 270/217 transaction in which a provider asks a health plan for information on a patient's eligibility for benefits and receives an answer from the plan.
HIPAA Health Care Claims or Equivalent Encounter Information/Coordination of Benefits  The HIPAA X12N 837 transaction that a provider uses to report professional, institutional, or dental claims and that is also used to send a secondary or tertiary payer claim with the primary payer's RA/EOB data.
HIPAA Health Care Payment and Remittance Advice  The HIPAA X12N 835 transaction used by a health plan to describe a payment in response to a health care claim.
HIPAA National Identifier  HIPPA-mandated identification systems for employers, health care providers, health plans, and patients; the NPI, National Provider System, and employer system are in place; health plan and patient systems are yet to be created.
HIPAA Privacy Rule  Law that regulates the use and disclosure of patients' protected health information (PHI).
HIPAA Referral Certification and Authorization  The HIPAA X12N 278 transaction in which a provider asks a health plan for approval of a service and the health plan responds, providing a certification number for an approved request.
HIPAA Security Rule  Law that requires covered entities to establish administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of health information.
HIPPA transaction  General term for the electronic transactions, such as claim status inquiries, health care claim transmittal, and coordination of benefits regulated under the HIPAA Health Care Transactions and Code Sets standards.
home health agency (HHA)  Organization that provides home care services to patients.
home health care  Care given to patients in their homes, such as skilled nursing care.
home plan  Blue Cross and Blue Shield plan in the community where the subscriber has contracted for coverage.
hospice  Public or private organization that provides services for terminally ill people and their families.
hospice care  Palliative care for people with terminal illnesses.
host plan  Participating provider's local Blue Cross and Blue Shield plan.
   

 

 

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ICD code  System of diagnosis codes based on the International Classification of Diseases.
ICD-9-CM  Abbreviated title of International Classification of Diseases, Ninth Revision, Clinical Modification.
ICD-9-CM Official Guidelines for Coding and Reporting  American Hospital Association publication that provides rules for selecting and sequencing diagnosis codes correctly in both the inpatient and outpatient environments.
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.
indemnify  A health plan's agreement to reimburse a policyholder for covered losses.
indemnity  Protection from loss.
indemnity plan  Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.
independent medical examination (IME)  Examination by a physician to confirm that an individual is permanently disabled that is conducted at the request of a state workers' compensation office or an insurance carrier.
independent (or individual) practice association (IPA)  Type of health maintenance organization in which physicians are self-employed and provide services to both HMO members and nonmembers.
indirect provider  Clinician who does not interact face-to-face with the patient, such as a laboratory.
individual deductible  Fixed amount that must be met periodically by each individual of an insured/ dependent group before benefits from a payer begin.
individual health plan (IHP)  Medical insurance plan purchased by an individual, rather than through a group affiliation.
individual relationship code  Administrative code that specifies the patient's relationship to the subscriber (insured).
information technology (IT)  The development, management, and support of computer-based hardware and software systems.
informed consent  The process by which a patient authorizes medical treatment after discussion about the nature, indications, benefits, and risks of a treatment a physician recommends.
initial preventive physical examination (IPPE)  Medicare benefit of a preventive visit for new beneficiaries.
inpatient  A person admitted to a medical facility for services that require an overnight stay.
Inpatient Prospective Payment System (IPPS)  Medicare payment system for hospital services; based on diagnosis-related groups (DRGs).
insurance aging report  A report grouping unpaid claims transmitted to payers by the length of time that they remain due, such as 30, 60, 90, or 120 days.
insurance commission  State's regulatory agency for the insurance industry that serves as liaison between patient and payer and between provider and payer.
insured  The policyholder or subscriber to a health plan or medical insurance policy; also known as guarantor.
intermediary  See fiscal intermediary.
internal audit  Self-audit conducted by a staff member or consultant as a routine check of compliance with reporting regulations.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)  Publication containing the HIPAA-mandated standardized classification system for diseases and injuries developed by the World Health Organization and modified for use in the United States.
   

 

 

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job reference aid  List of a medical practice's frequently reported procedures and diagnoses.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)  Organization that reviews accreditation of hospitals and other organizations/ programs.
   

 

 

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key component  Factor required to be documented for various levels of evaluation and management services.
   

 

 

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late effect  Condition that remains after an acute illness or injury has completed its course.
late enrollee  Category of enrollment in a commercial health plan that may have different eligibility requirements.
LCD  Local coverage determination.
Level II  HCPCS national codes.
Level II modifiers  HCPCS national code set modifiers.
liable  Legally responsible.
lifetime limit  See maximum benefit limit.
limiting charge  In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service.
line item control number  On a HIPAA claim, the unique number assigned by the sender to each service line item reported.
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.
Local Medicare Review Policy (LMRP)  See local coverage determination.
   

 

 

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main number  The five-digit procedure code listed in the CPT.
main term  The word in boldface type that identifies a disease or condition in the ICD-9-CM Alphabetic Index.
malpractice  Failure to use an acceptable level of professional skill when giving medical services that results in injury or harm to a patient.
managed care  System that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
managed care organization (MCO)  Organization offering some type of managed health care plan.
manifestation  Characteristic sign or symptom of a disease.
master patient index  Hospital's main patient database.
maximum benefit limit  The amount an insurer agrees to pay for an insured's covered expenses over the course of the insured person's lifetime.
M code  Classification number that identifies the morphology of neoplasms.
means test  Process of fairly determining a patient's ability to pay.
Medicaid  A federal and state assistance program that pays for health care services for people who cannot afford them.
MediCal  California's Medicaid program.
medical coder  Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.
medical error  Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
medical insurance  Financial plan that covers the cost of hospital and medical care.
medical insurance specialist  Medical office administrative staff member who handles billing, checks insurance, and processes payments.
medically indigent  Medically needy.
medically needy  Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance.
medical necessity  Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient's family.
medical necessity denial  Refusal by a health plan to pay for a reported procedure that does not meet its medical necessity criteria.
medical record  A file that contains the documentation of a patient's medical history, record of care, progress notes, correspondence, and related billing/ financial information.
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.
medical standards of care  State-specified performance measures for the delivery of health care by medical professionals.
medical terminology  The terms used to describe diagnoses and procedures; based on anatomy.
Medicare  The federal health insurance program for people sixty-five or older and some people with disabilities.
Medicare Advantage  Medicare plans other than the Original Medicare Plan.
Medicare beneficiary  A person covered by Medicare.
Medicare card  Insurance identification card issued to Medicare beneficiaries.
Medicare carrier  A private organization under contract with CMS to administer Medicare Part B claims in an assigned region.
Medicare Carriers Manual (MCM)  Guidelines established by Medicare about coverage for HCPCS Level II services; references to the MCM appear in the HCPCS code book.
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 Outpatient Adjudication remark codes (MOA)  Remittance advice codes that explain Medicare payment decisions.
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-participating agreement  Describes physicians and other providers of medical services who have signed agreements with Medicare to accept assignment on all Medicare claims.
Medicare Physician Fee Schedule (MPFS)  The RBRVS-based allowed fees that are the basis for Medicare reimbursement.
Medicare Redetermination Notice (MRN)  Resolution of a first appeal for Medicare fee-for-service claims; a written decision notification letter is due within sixty days of the appeal.
Medicare Secondary Payer (MSP)  Federal law requiring private payers who provide general health insurance to Medicare beneficiaries to be the primary payers for beneficiaries' claims.
Medicare Summary Notice (MSN)  Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined.
Medigap  Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage.
Medi-Medi beneficiary  Person who is eligible for both Medicare and Medicaid benefits.
Military Treatment Facility (MTF)  Government facility providing medical services for members and dependents of the uniformed services.
minimum necessary standard  Principle that individually identifiable health information should be disclosed only to the extent needed to support the purpose of the disclosure.
modifier  A number that is appended to a code to report particular facts. CPT modifiers report special circumstances involved with a procedure or service. HCPCS modifiers are often used to designate a body part, such as left side or right side.
monthly enrollment list  Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.
moribund  Approaching death.
multiple modifiers  Two or more modifiers used to augment a procedure code.
   

 

 

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National Committee for Quality Assurance (NCQA)  Organization that collects and disseminates the HEDIS information rating the quality of health maintenance organizations.
national coverage determination (NCD)  Medicare policy stating whether and under what circumstances a service is covered by the Medicare program.
National Patient ID (Individual Identifier)  Unique individual identification system to be created under HIPAA National Identifiers.
National Payer ID (Health Plan ID)  Unique health plan identification system to be created under HIPAA National Identifiers.
National Provider Identifier (NPI)  Under HIPAA, unique ten-digit identifier assigned to each provider by the National Provider System.
National Uniform Claim Committee (NUCC)  Organization responsible for the content of health care claims.
negligence  In the medical profession, failure to perform duties properly according to the state-required standard of care.
network  A group of providers having participation agreements with a health plan. Using in-network providers is less expensive for the plan's enrollees.
network model HMO  A type of health maintenance organization in which physicians remain self-employed and provide services to both HMO members and nonmembers.
new patient  A patient who has not received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years.
nonavailability statement  A form required for preauthorization when a TRICARE member seeks medical services in other than military treatment facilities.
noncovered services  Medical procedures that are not included in a plan's benefits.
nonparticipating (nonPAR) provider  A provider who chooses not to join a particular government or other health plan.
nontraumatic injury  A condition caused by the work environment over a period longer than one work day or shift; also known as occupational disease or illness.
not elsewhere classified (NEC)  An ICD-9-CM abbreviation indicating the code to be used when an illness or condition cannot be placed in any other category.
Notice of Contest  Carrier's determination to deny liability for an employee's workers' compensation claim.
Notice of Exclusions from Medicare Benefits (NEMB)  CMS form given by a participating provider to a Medicare patient before providing a noncovered service; provides written notification that Medicare will not pay and states the estimated charge for which the patient will be responsible.
Notice of Privacy Practices (NPP)  A HIPAA-mandated description of a covered entity's principles and procedures related to the protection of patients' health information.
not otherwise specified (NOS)  An ICD-9-CM abbreviation indicating the code to be used when no information is available for assigning the illness or condition a more specific code.
   

 

 

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observation services  Medical service furnished in a hospital to evaluate an outpatient's condition or determine the need for admission as an inpatient.
occupational diseases or illnesses  Conditions caused by the work environment over a period longer than one workday or shift; also known as nontraumatic injuries.
Occupational Safety and Health Administration (OSHA)  Federal agency that regulates workers' health and safety risks in the workplace.
Office for Civil Rights (OCR)  Government agency that enforces the HIPAA Privacy Act.
Office of the Inspector General (OIG)  Government agency that investigates and prosecutes fraud against government health care programs such as Medicare.
Office of Workers' Compensation Programs (OWCP)  The office of the U.S. Department of Labor that administers the Federal Employees' Compensation Act.
OIG Compliance Program Guidance for Individual and Small Group Physician Practices  OIG publication that explains the recommended features of compliance plans for small providers.
OIG Fraud Alert  Notices issued by the OIG to advise providers about potentially fraudulent or noncompliant actions regarding billing and reporting practices.
OIG Work Plan  The OIG's annual list of planned projects under the Medicare Fraud and Abuse Initiative.
open-access plans  Type of health maintenance organization in which a member can visit any specialist in the plan's network without a referral.
open enrollment period  Span of time during which a policyholder selects from an employer's offered benefits; often used to describe the fourth quarter of the year for employees in employer-sponsored health plans or the designated period for enrollment in a Medicare or Medigap plan.
operations (health care)  Activities such as conducting quality assessment and improvement, developing protocol, and reviewing the competence or qualifications of health care professionals and actions to implement compliance with regulations.
Original Medicare Plan  The Medicare fee-for-service plan.
other ID number  Additional provider identification number supplied on a health care claim.
out-of-network  A provider that does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan's enrollees.
out-of-pocket  Expenses the insured must pay before benefits begin.
outpatient  A patient who receives health care in a hospital setting without admission; the length of stay is generally less than twenty-three hours.
Outpatient Prospective Payment System (OPPS)  The payment system for Medicare Part B services that facilities provide on an outpatient basis.
outside laboratory  Purchased laboratory services.
overpayment  An improper or excessive payment to a provider as a result of billing or claims processing errors for which a refund is owed by the provider.
   

 

 

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panel  In CPT, a single code grouping laboratory tests that are frequently done together.
participating physician/provider (PAR)  A provider who agrees to provide medical services to a payer's policyholders according to the terms of the plan'scontract.
participation  Contractual agreement by a provider to provide medical services to a payer's policyholders.
password  Confidential authentication information composed of a string of characters.
patient aging report  A report grouping unpaid patients' bills by the length of time that they remain due, such as 30, 60, 90, or 120 days.
patient information form  Form that includes a patient's personal, employment, and insurance company data needed to complete a health care claim; also known as a registration form.
patient ledger  Record of all charges, payments, and adjustments made on a particular patient's account.
patient ledger card  Card used to record charges, payments, and adjustments for a patient's account.
patient refunds  Monies that are owed to patients.
patient statement  A report that shows the services provided to a patient, total payments made, total charges, adjustments, and balance due.
payer  Health plan or program.
payer of last resort  Regulation that Medicaid pays last on a claim when a patient has other insurance coverage.
pay-for-performance (P4P)  Health plan financial incentives program to encourage providers to follow recommended care management protocols.
payment plans  Patients' agreements to pay medical bills over time according to an established schedule.
pay-to provider  The person or organization that is to receive payment for services reported on a HIPAA claim; may be the same as or different from the billing provider.
PECOS  See Provider Enrollment Chain and Ownership System.
pending  Claim status during adjudication when the payer is waiting for information from the submitter.
permanent disability  Condition that prevents a person in a disability compensation program from doing any job.
permanent national codes  HCPCS Level II codes.
per member per month (PMPM)  Periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits.
pharmacy  Facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
pharmacy benefit manager  Company that operates an employer's pharmacy benefits program, buying drugs, setting up the formulary, and pricing the prescriptions for the insured.
physical status modifier  Code used in the Anesthesia Section of CPT with procedure codes to indicate the patient's health status.
physician of record  Provider under a workers' compensation claim who first treats the patient and assesses the level of disability.
place of service (POS) code  HIPAA administrative code that indicates where medical services were provided.
plan summary grid  Quick-reference table for frequently billed health plans.
point-of-service (POS) option  In HMOs, plan that permits patients to receive medical services from non-network providers; this choice requires a larger patient payment than visits with network providers.
policyholder  Person who buys an insurance plan; the insured, subscriber, or guarantor.
practice management program (PMP)  Business software designed to organize and store a medical practice's financial information; often includes scheduling, billing, and electronic medical records features.
preauthorization  Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered.
precertification  Generally, preauthorization for hospital admission or outpatient procedure; See preauthorization.
preexisting condition  Illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
preferred provider organization (PPO)  Managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
premium  Money the insured pays to a health plan for a health care policy.
prepayment plan  Payment before medical services are provided.
preventive medical services  Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.
Primary Care Manager (PCM)  Provider who coordinates and manages the care of TRICARE beneficiaries.
primary care physician (PCP)  A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
primary diagnosis  Diagnosis that represents the patient's major illness or condition for an encounter.
primary insurance (payer)  Health plan that pays benefits first when a patient is covered by more than one plan.
primary procedure  The most resource-intensive (highest paid) CPT procedure done during a patient's encounter.
principal diagnosis (PDX)  The condition that after study is established as chiefly responsible for a patient's admission to a hospital.
principal procedure  The main service performed for the condition listed as the principal diagnosis for a hospital inpatient.
prior authorization number  Identifying code assigned by a government program or health insurance plan when preauthorization is required; also called the certification number.
private disability insurance  Insurance plan that can be purchased to provide benefits when illness or injury prevents employment.
privileging  The process of determining a health care professional's skills and competence to perform specific procedures as a participant in, or an affiliate of, a health care facility or system. Once a facility privileges a practitioner, the practitioner may perform those specific procedures.
procedure code  Code that identifies medical treatment or diagnostic services.
professional component (PC)  The part of the relative value associated with a procedure code that represents a physician's skill, time, and expertise used in performing it; contrast with the technical component.
professional courtesy  Providing free medical services to other physicians.
prognosis  The physician's prediction of outcome of disease and likelihood of recovery.
progress report  A report filed by the physician in state workers' compensation cases when a patient's medical condition or disability changes; also known as a supplemental report.
prompt-pay laws  Regulations that obligate payers to pay clean claims within a certain time period.
prospective audit  Internal audit of particular claims conducted before they are transmitted to payers.
prospective payment  Payment for health care made before the services are provided.
Prospective Payment System (PPS)  Medicare system for payment for institutional services.
protected health information (PHI)  Individually identifiable health information that is transmitted or maintained by electronic media.
provider  Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
Provider Enrollment Chain and Ownership System (PECOS  CMS national database of participating providers.
provider-sponsored organization (PSO)  Capitated Medicare managed care plan in which the physicians and hospitals that provide treatment also own and operate the plan.
provider withhold  Amount withheld from a provider's payment by an MCO under contractual terms; may be paid if stated financial requirements are met.
   

 

 

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qualifier  Two-digit code for a type of provider identification number other than the National Provider Identifier (NPI).
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.
qui tam  "Whistle-blower" cases in which a relator accuses another party of fraud or abuse against the federal government.
   

 

 

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RA/EOB  Remittance advice/explanation of benefits. Payer document detailing the results of claim adjudication and payment.
real-time  Information technology term for computer systems that update information the same time they receive it; the sender and receiver "converse" by inquiring and responding to data while remaining connected.
reasonable fee  The lower of either the fee the physician bills or the usual fee, unless special circumstances apply.
reconciliation  Comparison of two numbers to determine whether they differ.
redetermination  First level of Medicare appeal processing.
referral  Transfer of patient care from one physician to another.
referral number  Authorization number given by a referring physician to the referred physician.
referral waiver  Document a patient is asked to sign guaranteeing payment when a required referral authorization is pending.
referring physician  The physician who refers the patient to another physician for treatment.
registration  Process of gathering personal and insurance information about a patient during admission to a hospital.
relative value scale (RVS)  System of assigning unit values to medical services based on an analysis of the skill and time required of the physician to perform them.
relative value unit (RVU)  A factor assigned to a medical service based on the relative skill and time required to perform it.
relator  Person who makes an accusation of fraud or abuse in a qui tam case.
remittance  The statement of the results of the health plan's adjudication of a claim.
remittance advice (RA)  Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB).
remittance advice remark codes (REM)  Codes that explain payers' payment decisions.
rendering provider  Term used to identify the physician or other medical professional who provides the procedure reported on a health care claim if other than the pay-to provider.
reprice  Contractual reduction of a physician's fee schedule.
repricer  Vendor that processes out-of-network claims for payers.
required data element  Information that must be supplied on an electronic claim.
resource-based fee structure  Setting fees based on the relative skill and time required to provide similar services.
resource-based relative value scale (RBRVS)  Federally mandated relative value scale for establishing Medicare charges.
respondeat superior  Doctrine making the employer responsible for employees' actions.
responsible party  Person or entity other than the insured or the patient who will pay a patient's charges.
restricted status  A category of Medicaid beneficiary.
retention schedule  A practice policy that governs which information from patients' medical records is to be stored, for how long it is to be retained, and the storage medium to be used.
retroactive payment  Payer's payment for health care after the services are provided
retrospective audit  An internal audit conducted after claims are processed by payers and after RAs have been received for comparison with submitted charges.
rider  Document that modifies an insurance contract.
roster billing  Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines.
   

 

 

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schedule of benefits  List of the medical expenses that a health plan covers.
screening services  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.
secondary condition  Additional diagnosis that occurs at the same time as a primary diagnosis and that affects its treatment.
secondary insurance (payer)  The health plan that pays benefits after the primary plan pays when a patient is covered by more than one plan.
secondary procedure  Procedure performed in addition to the primary procedure.
secondary provider identifier  On HIPAA claims, identifiers that may be required by various plans in addition to the NPI, such as a plan identification number.
section guidelines  Usage notes provided at the beginnings of CPT sections.
Section 125 cafeteria plan  Employers' health plans that are structured under income tax laws to permit funding of premiums with pretax payroll deductions.
self-funded (insured) employer  A company that creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physicians, and pays for claims from its fund.
self-pay patient  A patient who does not have insurance coverage.
separate procedure  Descriptor used in the Surgery Section of CPT for a procedure that is usually part of a surgical package but may also be performed separately or for a different purpose, in which case it may be billed.
service line information  On a HIPAA claim, information about the services being reported.
silent PPOs  Managed care organization that purchases a list of a PPO's participating providers and pays those providers' claims for its enrollees according the contract's fee schedule even though the providers do not have contracts with the silent PPO. A provider can avoid having to work with a silent PPO by making sure his or her contract includes language prohibiting the PPO from selling his or her name to another party.
situational data element  Information that must be supplied on a claim when certain other data elements are provided.
skilled nursing facility (SNF)  Health care facility in which licensed nurses provide nursing and/or rehabilitation services under a physician's direction.
skip trace  The process of locating a patient who has not paid on an outstanding balance.
small group health plan  Under HIPAA, generally a health plan sponsored by an employer with fewer than fifty employees.
SNODENT  Systemized nomenclature of dentistry.
SNOMED  Systemized nomenclature of medicine.
SOAP (subjective/objective/assessment/plan)  Documentation format in which encounter information is grouped into four sections containing the patient's subjective descriptions of signs and symptoms; the physician's notes on the objective information regarding the condition and examination/test results; the physician's assessment, or diagnosis, of the condition; and the plan of treatment.
Social Security Disability Insurance (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.
special report  Note explaining the reasons for a new, variable, or unlisted procedure or service; describes the patient's condition and justifies the proce-dure's medical necessity.
spend-down  State-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses.
sponsor  The uniformed service member in a family qualified for TRICARE or CHAMPVA.
staff model HMO  A type of HMO in which member providers are employees of the organization and provide services for HMO-member patients only.
standards of care (medical)  State-specified performance measures for the delivery of health care by medical professionals.
State Children's Health Insurance Program (SCHIP)  Program offering health insurance coverage for uninsured children under Medicaid.
statistical analysis durable medical equipment regional carrier (SADMERC)  CMS contractors who provide assistance in determining which HCPCS codes describe DMEPOS items for Medicare billing purposes.
stop-loss provision  Protection against the risk of large losses or severely adverse claims experience; may be included in a participating provider's contract with a plan or bought by a self-funded plan.
subcapitation  Arrangement under which a capitated provider prepays an ancillary provider for specified medical services for plan members.
subcategory  In ICD-9-CM, a four-digit code number.
subclassification  In ICD-9-CM, a five-digit code number.
subpoena  An order of a court for a party to appear and testify in a court of law.
subscriber  The insured.
subterm  Word or phrase that describes a main term in the ICD-9-CM Alphabetic Index.
Summary Plan Description (SPD)  Legally required document for self-funded plans that states beneficiaries' benefits and legal rights.
superbill  Listing of the diagnoses, procedures, and charges for a patient's visit; also called the encounter form.
supplemental insurance  Insurance plan, such as Medigap, that provides benefits for services that are not normally covered by a primary plan.
supplemental report  Report filed by the physician in state workers' compensation cases when a patient's medical condition or disability changes; also known as progress report.
Supplemental Security Income (SSI)  Government program that helps pay living expenses for low-income older people and those who are blind or have disabilities.
supplementary term  Nonessential word or phrase that helps define a code in the ICD-9-CM; usually enclosed in parentheses or brackets.
surgical package  Combination of services included in a single procedure code for some surgical procedures in CPT.
suspended  Claim status during adjudication when the payer is developing the claim.
   

 

 

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Table of Drugs and Chemicals  Reference listing of drugs and chemicals in the ICD-9-CM Alphabetic Index.
Tabular List  Section of the ICD-9-CM in which diagnosis codes are presented in numerical order.
taxonomy code  Administrative code set under HIPAA used to report a physician's specialty when it affects payment.
technical component  The part of the relative value associated with a procedure code that reflects the technician's work and the equipment and supplies used in performing it; in contrast to the professional component.
Telephone Consumer Protection Act of 1991  Federal law that regulates consumer collections to ensure fair and ethical treatment of debtors; governs calling hours and methods.
Temporary Assistance for Needy Families (TANF)  Government program that provides cash assistance for low-income families.
temporary disability  Condition that keeps a person with a private disability compensation program from working at the usual job for a short time, but from which the worker is expected to recover completely and return to work.
temporary national codes  HCPCS Level II codes available for use but not part of the standard code set.
tertiary insurance  The third payer on a claim.
third-party claims administrator (TPA)  Company that provides administrative services for health plans but is not a contractual party.
third-party payer  Private or government organization that insures or pays for health care on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
tiered network  Plan feature that pays more to providers that the plan rates as providing the highest-quality, most cost-effective medical services.
TPO  See treatment, payment, and operations.
trace number  A number assigned to a HIPAA 270 electronic transaction sent to a health plan to inquire about patient eligibility for benefits.
transaction  Under HIPAA, structured set of data transmitted between two parties to carry out financial or administrative activities related to health care; in a medical billing program, financial exchange that is recorded, such as a patient's copayment or deposit of funds into the provider's bank account.
traumatic injury  Injury caused by a specific event or series of events within a single workday or shift.
treatment, payment, and health care operations (TPO)  Under HIPAA, patients' protected health information may be shared without authorization for the purposes of treatment, payment, and operations.
TRICARE  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.
TRICARE Extra  TRICARE'S managed care health plan that offers a network of civilian providers.
TRICARE for Life  Program for beneficiaries who are both Medicare and TRICARE eligible.
TRICARE Prime  The basic managed care health plan offered by TRICARE.
TRICARE Reserve Select (TRS)  TRICARE coverage for reservists.
TRICARE Standard  The fee-for-service health plan offered by TRICARE.
truncated coding  Diagnoses that are not coded at the highest level of specificity available.
Truth in Lending Act  Federal law requiring disclosure of finance charges and late fees for payment plans.
   

 

 

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UB-04  Currently mandated paper claim for hospital billing.
UB-92  Former paper hospital claim; also known as the CMS-1450.
unbundling  The incorrect billing practice of breaking a panel or package of services/procedures into component parts and reporting them separately.
uncollectible accounts  Monies that cannot be collected from the practice's payers or patients and must be written off.
Uniform Hospital Discharge Data Set (UHDDS)  Classification system for inpatient health data.
unlisted procedure  A service that is not listed in CPT; it is reported with an unlisted procedure code and requires a special report when used.
unspecified  An incompletely described condition that must be coded with an unspecified ICD code.
upcoding  Use of a procedure code that provides a higher payment than the code for the service actually provided.
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.
usual, customary, and reasonable (UCR)  Setting fees by comparing the usual fee the provider charges for the service, the customary fee charged by most providers in the community, and the fee that is reasonable considering the circumstances.
usual fee  Fee for a service or procedure that is charged by a provider for most patients under typical circumstances.
utilization  Pattern of usage for a medical service or procedure.
utilization review  Payer's process to determine the appropriateness of hospital-based health care services delivered to a member of a plan.
utilization review organization (URO)  Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan.
   

 

 

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V code  Alphanumeric code in the ICD-9-CM that identifies factors that influence health status and encounters that are not due to illness or injury.
verification report  Report created by a medical billing program to permit double-checking of basic claim content before transmission.
vocational rehabilitation  Retraining program covered by workers' compensation to prepare a patient for reentry into the workforce.
   

 

 

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waiting period  Time period between an insured's date of enrollment and the date insurance coverage is effective.
waived tests  Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices.
walkout receipt  Medical billing program report given to a patient that lists the diagnoses, services provided, fees, and payments received and due after an encounter.
Welfare Reform Act  law that established the Temporary Assistance for Needy Families program in place of the Aid to Families with Dependent Children program and that tightened Medicaid eligibility requirements.
workers' compensation insurance  State or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.
write off  (noun: write-off) To deduct an amount from a patient's account because of a contractual agreement to accept a payer's allowed charge or for other reasons.







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