ProcedureFlow Glossaru

Question 1

ACA

Answer 1

Access Control Area is responsible for confidential communication.

The ACA area will automatically terminate existing Confidential Communication Requests and Restriction Requests for members whose coverage has been terminated for more than 18 months and notification will be sent to those members.

OR Affordable Care Act

Question 2

ACA Contraceptive Drug List

Answer 2

This includes a list of certain contraceptive drugs with coverage at no cost to the member when an in-network pharmacy is used.

Question 3

ACA Preventive Drug List

Answer 3

This list includes certain prescription and over-the-counter preventive medicines with coverage at no cost to the member when an in-network pharmacy is used

Question 4

Account (Acct)

Answer 4

A record of the type of policy including pertinent information.

A formal business arrangement providing or regular dealings or services and involving the establishment and maintenance of an account.

Question 5

AE

Answer 5

Account Executive is responsible for a variety of field office sales and sales support activities. Implementation and enrollment support, cross-selling lines of coverage, product education, customer service, and renewal.

They are also responsible for building and managing relationships with assigned brokers and agents for employer/employee benefits.

Question 6

AIF

Answer 6

Account Inquiry Failed is a system error and requires Help Desk assistance

Question 7

AUF

Answer 7

Account Update Failed is a system error and requires Help Desk assistance

Question 8

ACO

Answer 8

Accountable Care Organization are…
- collaborations of primary care professionals and other health service providers, such as physicians and hospitals…
- organized around the capacity to improve health outcomes and the quality of care while slowing the growth in overall costs for a population of patients cared for by a well-defined group of health care professionals
- capable of measuring improvements in performance and receiving payments that increase when such improvements occur

Question 9

A/P

Answer 9

Accounts Payable is a fee charged by a Host Plan for delivering the benefits of its provider contracts or networks to Home Plans. The access fee is computed as a percentage of the Host Plan’s discounts or differentials and may be charged only when the provider has agreed to hold the subscriber harmless

Question 10

A/R

Answer 10

Accounts Receivable is any money that a customer or client owes for a service or product they bought on credit. This money can be from goods they put on their store accounts, or from any unpaid invoices for services

Question 11

AR

Answer 11

Accounts Receivable is just a billing accounts receivable register screen in VMS

Question 12

AAE

Answer 12

Accums Audit Examiner ensures compliance with established internal control procedures by examining records, reports, operating practices, and documentation for accums. Completes audit work by documenting audit findings.

Question 13

Accums

Answer 13

Accumulations.. Accums is an abbreviation of accumulate, or any other form of the word accumulate or cumulative.

At HCSC, Accums generally refers to accounts or “buckets” that track accumulated amounts, such as deductibles paid. For example, “When making system updates or changes to an insured’s account, we want to ensure the insured’s Accums are not negatively effected.”

Question 14

AED

Answer 14

ACH Extract Drops is the batch process of pulling money from the member’s bank through the ACH network.

Question 15

ACL

Answer 15

Accumulator Coinsurance Limits is where the coinsurance is coded in GCPS

Question 16

ACP

Answer 16

Accumulator Copay prevents the copay from counting towards two costs…
1) the deductible
2) the maximum out-of-pocket spending

Question 17

ADL

Answer 17

Accumulator Deductible Limits is where all deductibles are coded in GCPS

Question 18

ATR

Answer 18

Accumulator Transfer Record

The Accumulator Conversion process uses a standard file format called ATR. This file layout is provided by the accumulator team to marketing and the vendor who creates the file to be transferred.

Question 19

ABI

Answer 19

Acquired Brain Injury is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, this type of brain injury is one that has occurred after birth. The injury results in a change to the brain’s neuronal activity, which affects the physical integrity, metabolic activity, or functional ability of nerve cells in the brain.

Question 20

Activity Codes

Answer 20

Various options that describe the action taken for particular inquiry.

Question 21

ACT

Answer 21

Activity. ACT or learning activities, as the name suggests, are activities designed or deployed by the teacher to bring about, or create the conditions for learning.

Activities record information or action taken to respond to a specific question raised by the customer.

Question 22

ACES

Answer 22

Actuarial Contract Evaluation System reprices claims based on the user selections. The user can select the provider, ranges of claims to reprice the claims under and allow for Charge Master adjustments.

The selected data is sent to the ACES system for repricing and then brought back to a SQL Server for reporting. There are standard reports available to the user. This is an enterprise application.

Question 23

Actuarial Values

Answer 23

A measure of the percentage of healthcare costs that are paid by a health insurance plan.

Question 24

ADM

Answer 24

Ad Hoc Document Management requires no action on the part of your tenants, and is not triggered by any action in your software.

Question 25

ALIM

Answer 25

Add Line Item Manager is an automated, real-time process for claim adjudication generally utilized by larger accounts.

Question 26

CO2

Answer 26

(Add Only Work Item Type) code used to scan, email, or fax as an add only work type to FAF.

Question 27

Addl

Answer 27

(Additional) Added, extra, or supplementary to what is already present or available.

Question 28

AIL

Answer 28

Additional Information Letter, this term is used for any item that contains additional information. The items can be in many different work queues on Image, not only the AIL queue. AIL is used to describe…

• Coordination of Benefits Subscriber Questionnaires
• Medical records
• Operative reports
• Pre-existing questionnaires
• Responses to request for description of services
• Responses to requests for additional information

Question 29

ASOP

Answer 29

Additional Surgical Opinion Program is a plan that benefits which covers charges incurred by a member when he visits one of the program’s designated surgeons in order to receive an additional opinion on whether or not elective surgery recommended by the member’s own physician is medically necessary.

Question 30

ATIN

Answer 30

Adoption Taxpayer Identification Number is a number issued by the Internal Revenue Service as a temporary taxpayer identification number for the child in a domestic adoption where the adopting taxpayers do not have and/or are unable to obtain the child’s SSN.

Question 31

ATCP

Answer 31

When added to a contract, Additional Surgical Opinion Program covers travel and lodging for the transplant recipient and a traveling companion.

Question 32

ATB

Answer 32

Address to Bill. It’s the billing address, the address that their bill is sent to.

Question 33

ATR

Answer 33

Address to Rate is the physical address for a member. A physical address is a real street address that can be used as a personal or business mailing address. A physical address does not have the same delivery restrictions as a PO Box.

Question 34

ATU

Answer 34

Address to Use is the member’s mailing address.

Question 35

ATT

Answer 35

Adjacent Tissue Transfer An adjacent tissue transfer, also known as a rearrangement procedure or simply ATT/R, is a medical procedure wherein flat sections of healthy skin and other tissues are transferred or transplanted to the area adjacent to a skin defect. These sections of tissue are called local flaps and are used to cover up defects or lesions on the surface of the skin. This procedure, which can be performed on any part of the body, including the trunk, scalp, arms, and legs, promises better cosmetic results because the donor skin and the skin immediately surrounding the wound or lesion have the same features.

Question 36

ADJ

Answer 36

An adjustment made when claim status changes due to new information. For example, a claim adjustment is made when a claim which was previously denied is now payable due to additional information being received.

Question 37

ADJUSTREQ

Answer 37

Adjustment Request is used to approve adjustment request message when ITS claim cannot be streamline adjusted

Question 38

ARRM

Answer 38

Adjustment Request/Response Message is a message used to respond to an adjustment request on ITS claims that cannot be streamline adjusted

Question 39

ADJUSTRESP

Answer 39

Adjustment Response is used to approve adjustment request message when ITS claim cannot be streamline adjusted

Question 40

A/J

Answer 40

Admin Fee Report is an accounting report that lists all of the participants and fees that are charged to a group.

Question 41

ADMIN

Answer 41

Administration is well.. duh..

Question 42

AD

Answer 42

Admin Date is the date the services will begin, the start date; date of admission

Question 43

ADM

Answer 43

Admit Source Code is a code that best describes the origin of the patient’s admission to the hospital

Question 44

ABN

Answer 44

Advanced Beneficiary Notice is issued by providers, physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.

Question 45

ACR

Answer 45

Advanced Check Request is a tool that provides the ability to see where an ACR is at all times. The ACR tool has multiple queues and status types that make it easier to track an ACR, and to monitor inventory and production.

Question 46

ACP

Answer 46

Advanced Clinical Practitioner are experienced healthcare professionals with a Masters level award of equivalent who have developed their skills and knowledge to take on expanded roles and scopes of patient care.

Question 47

ALS

Answer 47

An ambulance in which Advanced Life Support is provided in situations where the patient being transported is in a more critical condition and a paramedic is required to assist in the treatment of the patient before and/or during transport to the emergency facility.

Question 48

ANP

Answer 48

Advanced Nurse Practitioner is a nurse with a post-graduate education in nursing. They are prepared with advanced didactic and clinical education.

Question 49

APR

Answer 49

Advanced Payment Reviews are prepayment reviews completed for ASO 151+ groups who purchased a buy option effective 01/01/2022