Ch. 12 Terms Flashcards
Advance Beneficiary Notice of Noncoverage (ABN)
An agreement given to the patient to read and sign before rendering a service if the participating doctor thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. The patient agrees to pay for the service’ also known as a “waiver of liability agreement” or “responsibility statement”.
Approved charges
A fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the service
Assignment
A transfer, after an event insured against, or an individual’s legal right to collect an amount payable under an insurance contract. The provider accepts the terms of the insurance contract between the patient and carrier; for Medicare, the provider accepts 80% of the allowed amount as payment in full once the deductible has been met.
Benefit period
A period of time during which payments for Medicare inpatient hospital benefits are available (begins the first day an enrollee is given inpatient hospital care and ends when they haven’t been an inpatient for 60 consecutive days).
Centers for Medicare and Medicaid Services
Formerly known as the Health Care Financing Administration (HCFA), CMS divides responsibilities among 3 divisions: the Center for Medicare Management, the Center for Beneficiary Choices, and the Center for Medicaid and State Operations
Correct Coding Initiative
Federal legislation that attempt to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients.
Crossover claim
Also known as claims transfer, this is a when a bill of services are first paid by Medicare and whatever unmet amount is automatically electronically transferred to the secondary insurance for additional payment
Diagnostic cost groups (DCGs)
A system of Medicare reimbursement for HMOs with risk contracts in which enrollees are classified into various DCGs on the basis of each beneficiary’s prior 12 month hospitalization history.
Disabled
Individuals younger than 65 who have been entitled to disability benefits under the Social Security Act or the Railroad Retirement system for at least 24 months are considered disabled and are entitled to Medicare.
End- stage renal disease (ESRD)
Individuals who have chronic kidney disease requiring dialysis or kidney transplant are considered to have ESRD. Medicare coverage begins with the third month after beginning a course of renal dialysis.
Formulary
List of drugs that a health insurance plan covers as a benefit.
Hospice
A public agency or private organization primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill patients and their families in their own homes or in a homelike center.
Hospital insurance
Known as Medicare Part A
Intermediate care facilities
Institutions furnishing health related care and services to individuals who don’t require the degree of care provided by acute care hospitals or nursing facilities.
Limiting charge
A percentage limit on fees, specified by laws, that non participating doctors may bill medicare beneficiary above the fee schedule amount
Medical necessity
The performance of services and procedures that are consistent with the diagnosis. Medical necessity must be established before the carrier may make payment
Medicare
Nationwide health insurance plan for people 65 years or older and certain disabled and blind people regardless of income, administered by CMS. Local social security offices take applications and supply info to the program
Medicare administrative contractors (MAC)
Insurance carrier that receives and processes claims from providers for Medicare Part B
Medicare Part A
Hospital benefits for people age 65 and older and certain disabled individuals regardless of income
Medicare Part C
Medicare Plus Choice plans offer a number of health care options in addition to those available under Medicare Part A and B. Plans may include Medicare medical savings accounts, fee for service plans, etc.
Medicare Part D
Stand alone prescription drug plan
Medicare Secondary Payer
When Medicare is secondary; the primary insurance plan must pay for any medical services first, before Medicare picks up
Medicare Summary Notice
A document received by the patient explaining amount charged, deductible, etc, of medical services.
Medigap
Additional insurance policy for the medicare beneficiary that covers the deductible and copayment that’s not typically covered under the main Medicare policy
