Key Terms Flashcards
AAPC (American Academy of Professional Coders)
Professional association established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.
AAMA (American Association of Medical Assistants)
enables medical assisting professionals to enhance and demonstrate the knowledge skills and professionalism required by employers and patience, as well as protect medical assistance, rights to practice.
AHIMA (American Information Management Association)
Found it in 1928 to improve the quality of medical records, and currently advances the health information management profession toward an electronic and global environment, including implementation of ICD – 10 – CM and ICD – 10 – PCS in 2013.
Bonding insurance
And insurance agreement that guarantees repayment for financial losses, resulting from the act or failure to act of an employee. It protects the financial operations of the employer.
Business liability insurance
Protect business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising.
CMS (Centers for Medicare and Medicaid Services)
Formally known as the healthcare financing administration (HCFA); an administrative agency within the federal department of health and human services (DHHS).
Claims examiner
Employed by third-party payers to review health related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis.
Coder coding
Process of reporting diagnoses, procedures, services and supplies as numeric and alpha numeric characters (called codes) on the insurance claim.
Embezzle
The illegal transfer of money or property as a fraudulent action; steal money from an employer.
Errors and omissions insurance aka professional liability insurance
Provides protection from liability as a result of errors and submissions when performing their professional.
Ethics
Principle of right or good conduct; rules that govern the conduct of members of a profession.
Healthcare provider
Physician or other healthcare practitioner (eg physicians assistant).
Health information technicians
Professional human manage, patient health information and medical records, administer computer information systems, and code diagnoses and procedures for healthcare services provided to patients.
Health insurance claim
Documentation that is electronically or manually submitted to an insurance plan requesting reimbursement for healthcare procedures, and services provided.
Health insurance specialist aka reimbursement specialists
Person who reviews health related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider.
Hold harmless clause
Policy that the patient is not responsible for pain with the insurance plan denies.
Independent contractor
Defined by the lectric law library’s lexicon as “a person who performed services for another under an express or implied agreement, and who is not subject to the others control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the ax or emissions of the independent contractor.”
Internship
Nonpaid professional practice experience that benefits, students and facilities that accept students for placement; students receive on the job experience prior to graduation, and the internship assist them in obtaining permanent employment.
Medical assistant
Employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
Medical malpractice insurance
A type of liability insurance that covers physicians and other healthcare professionals for liability claims arising from patient treatment.
Medical necessity
Involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service.
Professionalism
Conduct or qualities that characterize a professional person.
Property insurance
Protects business, contents against fire, theft, or other risks.
Respondeat superior
Latin for let the master answer; legal doctrine, holding that the employer is liable for the actions and emissions of employees performed, and committed within the scope of their employment.
Scope of practice
Healthcare services determined by the state that an NP and a PA can perform.
Workers’ compensation insurance
Insurance program, mandated by federal and state governments that requires employers to cover medical expenses and loss of wage for workers who are injured on the job or who have developed job-related disorders.
Accreditation
Voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law.
Advanced alternative payment models (advanced APMs)
Include new ways for CMS to reimburse healthcare providers for care provided to Medicare beneficiaries; providers who participate in an advanced 8 PM through Medicare part B may earn an incentive payment for participating in the innovative payment model.
Alternative payment models (APMs)
Payment approach that includes incentive payments to provide high-quality and cost efficient care; APMs can apply to a specific clinical condition, a care episode, or a population.
Benchmarking
Practice that allows an entity to measure and compare its own data against that of other agencies and organizations for the purpose of continuous improvement (ie coding error rates)
Cafeteria plan
Also called triple option plan; provides different health, benefit plans and extra coverage options through an insurer or third-party administrator.
Capitation
prospective payment per patient for a prescribed period of time; provider accepts pre-established payments for providing healthcare services to enrolleyes over a specified period of time (usually one year or monthly).
Carve-out plan
Arrangement provided by a health insurance company to offer a specific health benefit that is managed separately from the health insurance plan.
Case manager
Cements written confirmation, authorizing treatment, to the provider; include nurses and social workers who help patients and families navigate complex, healthcare and support systems; also coordinate health care services to improve patient outcomes while considering financial implications as part of severity of illness and intensity of services (SI/IS) to dress the balance of medical necessity, procedures/services provided, and level of care needed.
Clinical practice guidelines
Define modalities for the diagnosis, management, and treatment of patients, and they include recommendations based on a methodical and meticulous evaluation, and synthesis of published medical literature; the guidelines are not protocols that must be followed, and instead are to be concerned.
CMS-1500 claim
Claim submitted for reimbursement of physician, office procedures in Services; electronic version is called ANSI ASC X12N 837P.
Coinsurance
Also called coinsurance payment; the percentage that patient pays for covered services after the deductible has been met, and the copayment has been made.
Competitive medical plan (CMP)
An HMO that meets federal eligibility requirements for a Medicare risk contract, but it’s not licensed as a federally qualified plan.
Consumer-directed health plan (CDHP)
Define employer contributions and asking employees to be more responsible for healthcare decisions, and cost sharing.
Continuity of care
Documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.
Copayment (copay)
Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a healthcare provider for each visit or medical service received.
Covered services (aka schedule of benefits)
Outline services covered by a health insurance plan.
Deductible
An amount for which the patient is financially responsible before an insurance policy provides reimbursement to the provider.
Electronic clinical quality measures (eCQMs)
Processes, observations, treatments, and outcomes that quantify the quality of care provided by healthcare systems; measuring such data helps ensure that car is delivered safely, effectively, equitably, and timely.
Enrollee (aka subscriber)
Individual who joins a managed care plan; subscribers also purchased traditional health insurance plans.
Excess insurance (aka stop-loss insurance)
Provides protection against catastrophic or unpredictable losses, and includes aggregate stop loss, plans and specific stop loss plans.
Exclusive provider organization (EPO)
Managed care plan that provides benefits to subscribers if they receive services from network providers.
Express contract
Provisions that are stated in a health insurance contract.
External quality review organization (EQRO)
Responsible for reviewing health care provided by managed care organizations.
Fee schedule
List of predetermined payments for healthcare services provided to patients (Ie a fee is assigned to each CPT code).
Fee-for-service
Reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services (ie brand name vs generic prescription medication).
Fee-for-service plans
Reimburses providers according to a fee schedule after covered procedures and services have been provided to patients.
Flexible spending accounts (FSA)
Consumer directed health plan that allows tax exempt accounts to be created by employees for the purpose of paying healthcare bills.
Gag clause
Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Gatekeeper
Primary care provider for essential healthcare services at the lowest possible cost, avoiding non-essential care, and referring patients to specialist.
Group health insurance
Private health insurance model that provides coverage, which is subsidized by employers and another organizations (ie labor unions, rural and consumer health cooperatives) whereby part all of premium costs are paid for and or discounted group rates are offered to eligible individuals.
Guaranteed renewal
A provision, when included in a health insurance contract, that requires a health insurance company to renew the policy as long as premiums continue to be paid.
Health care
Expands the definition of medical care to include preventative services.
Health care reimbursement account (HCRA)
Tax exempt account used to pay for healthcare expenses; individual decides in advance how much money to deposit in an HCRA (and unused funds are lost)
Health insurance
Contract between a policyholder and a third-party payer or government program to reimburse the policy holder for all or a portion of the cost of medically necessary, treatment or preventative care by healthcare professionals.
Health insurance exchange (aka health insurance marketplace)
Method Americans used to purchase health coverage that fits their budget and meets their needs, effective October 1 2013, as a result of passage of the affordable care act.
Health maintenance organization (HMO)
Responsible for providing healthcare services to subscribers in a given geographical area for a fixed fee.
Health reimbursement arrangement (HRA)
Tax-exempt account funded by employers, which individuals used to pay healthcare bills.
Health savings account (HSA)
Participants enroll in a relatively inexpensive, high deductible health plan (HDHP) and a tax deductible. Savings account is open to cover current and future medical expenses.
Health case effectiveness data and information set (HEDIS)
Created standards to assess managed care systems using data elements that are collected, evaluated, and published to compare the performance of manage healthcare plans.
Implied contract
Results from actions taken by the healthcare facility or provider, such as registering a patient to provide treatment.
Indemnity plan
Allows patient to see healthcare from any provider, and the provider receives reimbursement, according to a fee schedule; indemnity plans are sometimes called fee for service plans.
Individual health insurance
Private health insurance policy purchased by individuals or families who do not have access to group health insurance coverage; applicants can be denied coverage, and they can also be required to pay higher premiums due to age, gender, and/or pre-existing medical conditions.
Integrated delivery systems (IDS)
Organization of affiliated provider sites that offer joint healthcare services to subscribers.
Legislation
Federal state county, and municipal laws which are rules of conduct enforced by a threat of punishment if violated.
Lifetime maximum amount
Maximum benefit payable to a health plan, participant, such as annually or during a lifetime.
Major medical insurance
Coverage for catastrophic prolong illnesses and injuries, which can include hospital, medical common surgical benefits, that supplement basic coverage benefits.
Managed care
Health care delivery system organized to manage health care costs, utilization, and quality.
Managed care organization (MCO)
Responsible for the health of a group of enrollees; can be a health plan, hospital physician group or health system.
Mandates
Official directive, instruction, or order to take her perform a certain action, such as regulations written by federal government administrative agencies; they are also authoritative commands, such as by courts, governors, and legislatures.
Medical care
Includes the identification of disease and the provision of care and treatment as provide provided by members of the healthcare team to persons who are sick injured or concerned about their health status.
MIPS value pathways (MVPs)
Allow for a more cohesive provider, participation experience by connecting activities and measures from four merit-based incentive payment systems (MIPS) performance categories, irrelevant to a specialty, medical condition, or episode of care; MVP performance categories include quality, performance, improvement, activities, cost, and foundational layer (ie population health measures, promoting interoperability); see also traditional merit based incentive payment system (MIPS), which is the basis of MVPs.
National Committee for Quality Assurance (NCQA)
A private, not-for-profit organization, that assesses the quality of managed care plans in the United States and releases the data to the public for its consideration when selecting a managed care plan.
Network provider
Physician, healthcare practitioner, or healthcare facility under contract to the manage care plan.
Payer mix
Different types of health insurance payments made to providers for patient services.
Performance measurements
Strengthen organization, accountability, and support performance improvement initiatives by assessing the degree to which evidence based treatment guidelines are followed, and include in evaluation of results of care.
Personal health record (PHR)
Web-based application that allows individuals to maintain and manage their health information(and that of others for whom they are authorized, such as family) in a private, secure, and confidential environment.
Physician incentive plan
Requires managed care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans to CMS or state medicate agencies before a new renewed contract receives final approval.
Physician incentives
Include payments made directly or indirectly to healthcare providers to service encouragement to reduce our limit (ie discharge an inpatient from hospital more quickly) to save money for the managed care plan.
Physician referral
Written order by a primary care provider that facilitates patient evaluation and treatment by a physician specialist.
Point-of-service plan (POS)
Delivers healthcare services using both managed care network and traditional indemnity coverage so patient can see care outside the managed care network.
Policyholder
The person who signs a contract with a health insurance company and who, thus, owns the health insurance policy.
Preferred provider organization (PPO)
Network of physicians, or healthcare practitioners, and hospitals that have joined together to contract with insurance companies, or employers or other organizations to provide healthcare subscribers for a discounted fee.
Premium
Amount paid for a health insurance policy.
Prepaid health plan
Captation contract between a health plan and providers who manage all of the healthcare for a patient population and are reimbursed a predetermined amount of money either monthly or annually.
Prescription management
Controls medication costs using a variety of strategies, which include pharmacy, benefit, managers, cost, sharing, copayments or coinsurance, disease, management programs, electronic prescribing, drug formulas, drug utilization review, generic substitution, manufacturer, drug, rebates, negotiated prices, and prescription mail services.
Preventive services
Designed to help individuals avoid problems with health and injuries.
Primary care provider (PCP)
Responsible for supervising and coordinating health care services for enrolling and pre-authorizing referrals to specialist and inpatient hospital admissions (except in emergencies).
Promoting interoperability programs (PI)
Focus on improving patient access to health information and reducing the time cost required of providers to comply with the programs requirement; previously called EHR incentive programs.
Public health insurance
Federal and state government health programs (ie Medicare, Medicaid, CHIP, TRICARE) available to eligible individuals.
Quality assessment and performance improvement (QAPI) program
Program implemented so the quality assurance activities are performed to improve the functioning of Medicare advantage organizations.
Quality assurance program (aka quality management program)
Activities that assess the quality of care provided in a healthcare setting.
Quality improvement (QI)
Involves continuous and systematic actions that result in measurable improvement in the provision of healthcare services in the health status of targeted patient groups.
Quality improvement organizations (QIO)
Perform utilization and quality control review of healthcare furnished, or to be furnished to medical beneficiaries.
Quality improvement system for managed care (QISMC)
Established by Medicare to ensure that accountability of managed care plans in terms of objective, measurable standards.
Quality payment program (QPP)
Helps providers for us on quality of patient care and making patients healthier; includes advanced alternative payment models (Advanced APMs) and merit-based incentive payment system (MIPS); replaced the EHR Incentive Program (or Meaningful Use), Physician Quality Reporting System, and Value-Based Payment Modifier program.
Record linkage
Allows patient information to be created at different locations according to unique patient identifier or identification number.
Report card
Contains data regarding a managed, care, plans, quality, utilization, customer, satisfaction, administrative effectiveness, financial stability, and cost control.
Rider
Special contract clause stipulating additional coverage above the standard contract.
Risk adjustment program
Lessons or eliminate the influence of risk selection on premiums charged by health plans and includes the risk adjustment model and risk transfer formula.
Risk contract
An arrangement among providers to provide capitated (fixed, prepaid basis) healthcare services to Medicare beneficiaries.
Schedule of benefits
Outlines services covered by a health insurance plan.
Second surgical opinion (SSO)
Second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery.
Self-insured (or self-funded) employer-sponsored group health plans
Allows a large employer, to assume the financial risk for providing healthcare benefits to employees; employer does not pay a fixed premium to a health insurance, payer, but establishes a (of employer and employee contributions) out of which claims are paid.
Self-referral
Enrollee who sees a non-HMO panel specialist without a referral from the primary care physician
Single-payer health system
National health service model adopted by some western nations (ie Canada, Great Britain) and funded by taxes. The government pays for each residence healthcare, which is considered a basic social service.
Socialized medicine
Type of single pair system in which the government owns an operates healthcare facilities, and providers (ie physicians) receive salary; the VA healthcare program is a form of socialized medicine.
Standards
Requirements established by accreditation organizations.
Stop-loss insurance
Provide provides protection against catastrophic or unpredictable losses, and include aggregate stop loss, plans and stop specific plans.
Third-party administrators (TPAs)
Company that provides health benefits, claims administration and other outsourcing services (or employee benefits management) for self insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims, serving as a system of checks and balances for labor – management.
Third-party payer
The health insurance company that provides coverage, such as Blue Cross Blue Shield.
Total practice management software (TPMS)
Used to generate the EMR, automating medical practice functions of registering patients, scheduling appointments, generating insurance claims and patient statements, processing payments from patients in third-party payers, and producing administrative in clinical reports.
Traditional merit-based incentive payment system (MIPS)
Allows providers to earn a performance based payment adjustment that considers quality, resource use, clinical practice, improvement, and promoting interoperability; see also MIPS value pathways which evolved from traditional MIPS to allow for a more cohesive power participation experience.
Triple option plan
Usually offered by either a single insurance plan or as a joint venture among two or more third-party payers, and provide subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans; also called cafeteria plan or flexible benefit plan.
Universal health insurance
Goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal
Utilization review organization
Entity that establishes a utilization management program and performs external utilization review services.
Revenue management
The process by which healthcare facilities and providers ensure their financial viability by increasing revenue, improving cash flow and enhancing the patient’s experience. A.k.a. accounts receivable accounts, payable and quality of patient care.
Revenue cycle management
A revenue cycle process that typically begins upon appointment scheduling or physician order for an inpatient hospital admission and it concludes when reimbursement obtained through collections has been posted. A.k.a. accounts receivable management.
Institutional billing (aka facility billing)
Involves generating UB – 04 claims for charges generated for inpatient and outpatient services provided by healthcare facilities, which, according to CMS includes hospitals, long-term care, facilities, skilled nursing facilities, home health, agencies, hospice, organizations, and stage renal disease providers, outpatient physical therapy Services, comprehensive outpatient, rehab, facilities, community, mental health centers, critical access, hospitals, federally, qualified health centers, history, compatibility, laboratories, Indian health, service, facilities, Oregon procurement organizations, religious, non-medical, healthcare, institution, and rural health clinics.
Professional billing
Involves generating CMS – 1500 claims for charges generated for professional services and supplies provide provided by physicians and non-physician practitioners, which, according to CMS include nurse practitioners, physician, assistance, clinical nurse, midwives, certified registered, nurse anesthetists, and clinical nurse specialist.
Discharged not final fill coded (DNFC) and discharged not final billed (DNFB)
Involve patient claims that are not finalized because of coding delays in incomplete documentation or billing delays.
Claims rejections vs claims denials
Rejections are unpaid claims that failed to meet certain data requirements, such as missing data rejected claims can be corrected and resubmitted for processing. Denial are unpaid claims that contain beneficiary, identification errors, coding errors diagnoses that do not support the medical necessity of procedures or services performed, duplicate claims, global global delays of surgery, coverage issues, and other patient issues.
Integrated revenue cycle (IRC)
In case in utilization management, clinical documentation improvement, coding and health information and management are coordinated as part of the revenue management process.
Patient portal
Secure online website or cell phone application that provides patients with 24 hour online access to patient health information, appointment scheduling, messaging, and payment methods.
Guarantor
Person responsible for paying charges.
Participating provider (PAR)
Provider that contracts with the health insurance plan and accept whatever the pay reimburses for procedures or services performed. Participating providers are not allowed to bill patients for the difference between the contracted rate and their normal fee.
Non-participating provider (nonPAR)
Also called an out of network provider. Does not contract with the insurance plan, and the patients who like to receive care from non-participating providers will encourage higher out-of-pocket expenses. The patient is usually expected to pay the difference between the insurance admin and the providers fee, which is referred to as balance billingbalance billing is prohibited by state workers compensation plans in federal government programs, such as Medicaid Medicare TRICARE.
Single-path coding
Combined p professional and institutional coding to improve productivity and ensure the submission of clean claims, leading to improved reimbursement.
Encounter form
The financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. In the physicians office, it is also called a super Bill; in the hospital it’s called a charge master.
Chargemaster (aka charge description master CDM)
A document that contains a computer-generated encounter form that includes a list of procedures, Services, supplies and revenue codes with charges for each.
Revenue code
A four-digit code pre-printed on a facilities charge master to indicate the location or type of service provided to an institutional patient. Revenue codes are reported in form locator 42 of the UB – 04 claim.
Accept assignment
The provider agrees to accept with the insurance company allows or approved his payment info for the claim. The patient is responsible for paying any copayment and or coinsurance amounts.
Assignment of benefits
The patient and/or insured authorize the pay to reimburse the provider directly.
Out-of-pocket payment
Established by health insurance companies for a health insurance plan usually has limits of $1000 or $2000; when the patient has reached the limit of an out-of-pocket payment for the year appropriate patient reimbursement to the provider is determined; not all health insurance plans include an out-of-pocket payment provision.
Patient ledger or a patient account record
A permanent record of all financial transactions between the patient and the practice the charges along with personal or third-party payments are posted on the patient’s account. Each transaction must be individually described when entered on the patient ledger/account record.
Day sheet
Called manual daily accounts, receivable journal; chronological summary used to manually track all transactions posted to individual patient ledgers/accounts on a specific day.
Quarterly provider update updates (QPU’s)
Simplify the process of understanding, proposed or changes to its programs (Medicaid/medicare/Chip)
Utilization management aka utilization review
A method of controlling healthcare costs and quality of care by reviewing the appropriateness and medical necessity of care provider to patients prior to the administration of care or aftercare has been provided.
Case management
Involves the development of patient care plans for the coordination and provision of care for complicated cases in a constant effective manner.
Revenue monitoring
Involves assessing the revenue cycle to ensure financial viability and stability using the following metrics which are standards of measurement: cash flow, days and accounts receivable percentage of accounts receivable older than 30, 60, 90 and 120 days net collection rate and denial rate.
Revenue auditing
Assessment process that is conducted as a follow up to revenue monitoring so that areas of poor performance can be identified and corrected.
CMS-1500
Insurance claim used to report, professional and technical services
Resource allocation
Distribution of financial resources among competing groups.
Data analytics
Tools and systems that are used to analyze, clinical and financial data, conduct research, and evaluate the effectiveness of disease treatments.
Claims management
Performed to complete, submit and follow up on claims for procedures and services provided.
Claim submission
The electronic or manual transmission of claims stated to payers, clearing houses, or third-party administrators for processing. Prior submission claim scrubber software is used to review medical claims for coding and billing accuracy and other possible errors before submitting them.
Clearinghouse
An agency organization, that collects, processes, and distributes claims.
Explanation of benefits (EOB)
Details about the results of claim processing, such as provider charge, pay your fee scheduled, payment made by the pay, and patient financial responsibility.
Remittance advice - aka remit
Sent to providers by third-party payers that contains details about claims adjudication, including information about payments, deductibles and copayments, adjustments, denial, missing or inaccurate data, refunds, and claims, without due to secondary payer, third-party liability or penalty situations.
Electronic file format a.k.a. electronic media claim
Series of fixed length records submitted to payers as a bill for healthcare services
Electronic data interchange (EDI)
The computer to computer transfer data between providers and third-party payers in a data format agreed-upon by sending and receiving parties. The three formats acceptable are UB – 04 flat file format, national standard format. (NSF), or ANSI ASC X 12N 837 format.
Covered entities
Process electronic claims and include all private sector health plans
Clean claim
Correctly completed standardized claim (ie CMS-1500 claim).
Claims attachment
A set of supporting documentation or information associated with a healthcare claim or patient encounter. These are used for a medical evaluation for payment, past payment, audit, or review, and quality control to ensure access to care and quality of care.
Coordination of benefits (COB)
A provision in group health insurance policies intended to keep multiple insurance from paying benefits, covered by other policies.
Claims processing
Sorting claims upon submission to collect and verify information about the patient and provider.
Claims adjudication
Comparing a claim to pair edits, and the patient’s health plan benefits to verify that required information is available to process the claim, the claim is not a duplicate, pay rules and procedures have been followed, and procedures performed, and service is provided our covered benefits.
Common data file
Summary abstract report of all recent claims filed on each patient
Downcoding
Assigning lower-level codes than documented in the record.
Unbundling a.k.a. fragmentation
Submitting multiple CPT codes when one code should be submitted
Upcoding
Assignment of an ICD – 10 – CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement.
Source document
The routing slip, charge slip, encounter form, or super Bill form which the insurance claim was generated.
Open claims
Submitted to the pay, but processing is not complete.
Closed claims
Claims for which all processing, including appeals, has been completed.
Unassigned claims
Generated for providers who do not accept assignment; organized by year
Denied claims
Claim returned to the provider by payers due to coding errors, missing information, and paging coverage issues.
Claims adjustment reason codes (CARC)
Reasons for denied or rejected claims as reported on the remittance advisor explanation of benefits.
Remittance advice remark codes (RARC)
Additional explanation of reasons for denied claims.
Appeal
Documented as a letter and signed by the provider to explain why a claim should be reconsidered for payment.
Peer review
Appeal process performed to determine whether to reverse a pulled claims denial. Evaluation of the appeal is performed by a medical reviewer or a medical Director and if appeal is escalated and independent, external review may assess the appeal.
