Reimbursement Terminology

Question 1

Advance Beneficiary Notice

Answer 1

ABN, notification in advance of services that Medicare may not pay for them, including the estimated cost to the patient

Question 2

Ancillary Service

Answer 2

a service that is supportive of care of a patient, such as lab services

Question 3

APC

Answer 3

a classification system used to group like services based upon clinical similarities and resources utilized

Question 4

Assignment

Answer 4

a legal agreement that allows the provider to receive direct payment from a payer and the provider to accept payment as payment in full for covered services

Question 5

Attending Physician

Answer 5

the physician legally responsible for oversight of an inpatient’s care

Question 6

Beneficiary

Answer 6

the person who benefits from insurance coverage, also known as subscriber, dependent, enrollee, member, or participant

Question 7

Birthday Rule

Answer 7

when both parents have insurance coverage, the patient with the birthday earliest in the year is the primary coverage for a dependant

Question 8

Certified Registered Nurse Anesthetist

Answer 8

CRNA, an individual with specialized training and certification in nursing and anesthesia

Question 9

Charge Description Master

Answer 9

record of services, procedures, supplies, and drugs with corresponding codes, descriptions, and charges billed

Question 10

Co-Insurance

Answer 10

cost-sharing of covered services

Question 11

Compliance Plan

Answer 11

written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with third-party payer guidelines

Question 12

Concurrent Care

Answer 12

more than one physician providing care to a patient at the same time

Question 13

Coordination of Benefits

Answer 13

COB, management of multiple third-party payments to ensure overpayment does not occur

Question 14

Co-Payment

Answer 14

cost-sharing between beneficiary and payer

Question 15

Correct Coding Initiative

Answer 15

CCI, developed by CMS to control improper unbundling of CPT codes leading to inapproproate payment; also known as NCCI (National Correct Coding Initiative)

Question 16

Deductible

Answer 16

that portion of covered services paid by the beneficiary before third-party payment begins

Question 17

Denial

Answer 17

statement from the payer that reimbursement is denied

Question 18

Documentation

Answer 18

detailed chronology of facts and observations regarding a patient’s health

Question 19

DRGs

Answer 19

a case mix classification system established by CMS consisting of classes of patients who are similar clinically and in consumption of hospital resources, replaced with MS-DRGs

Question 20

Durable Medical Equipment

Answer 20

DME, medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers

Question 21

Electronic Data Interchange

Answer 21

EDI, computerized submission of health care insurance information exchange

Question 22

Employer Idenitification Number

Answer 22

EIN, an Internal Revenue Service (IRS)- issued identification number used on tax documents

Question 23

Encounter Form

Answer 23

medical document that contains information regarding a patient visit for health care services

Question 24

Explanation of Benefits

Answer 24

EOB, written, detailed listing of medical service payments by third-party payer to inform beneficiary and provider of payment

Question 25

Fee Schedule

Answer 25

established list of payments for medical services, i.e. lab, physician services

Question 26

Follow-Up Days

Answer 26

FUD, established by third party payers and listing the number of days after a procedure for which a provider must provide normal uncomplicated related services to a patient for no fee (also known as global days, global package, or global period)

Question 27

Group Provider Number

Answer 27

GPN, numeric designation for a group of providers that is used instead of the individual provider number

Question 28

Hospital Payment Monitoring System

Answer 28

HPMS, an inpatient PPS audit system used by CMS to reduce improper payments

Question 29

Invalid Claim

Answer 29

claim that is missing necessary information and cannot be processed or paid

Question 30

Inpatient

Answer 30

CMS defines an inpatient as a person who has been formally admitted to a hospital with the expectation that he or she will remain at least overnight and occupy a bed even if it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight

Question 31

Medical Record

Answer 31

documentation about the health care of a patient

Question 32

Medicare Administrative Contractors

Answer 32

MACs replaced Fiscal Intermediaries (FIs)

Question 33

Medicare Severity Diagnosis-Related Groups

Answer 33

MS-DRGs, classification system implemented October 2007 that is based on the principal diagnosis, and the medical or surgical service provided to the Medicare inpatient in which the hospital/facility is paid a fixed amount for each patient discharged in a treatment category

Question 34

National Correct Coding Initiative

Answer 34

developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment; also known as CCI (Correct Coding Initiative

Question 35

Noncovered services

Answer 35

any service not included by a third-party payer in the list of services for which payment is made

Question 36

National Provider Identifier

Answer 36

NPI, a 10-digit number assigned to provider and used for identification purposes when submitting services to third-party payers

Question 37

Hospital Outpatient

Answer 37

an individual who is not an inpatient of a hospital but who is registered as an outpatient at the hospital

Question 38

Prior Authorization

Answer 38

also known as preauthorization, which is a requirement by the payer to receive written permission prior to patient services if the service is to be considered for payment by the payer

Question 39

Provider Identification Number

Answer 39

PIN or UPIN, assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers

Question 40

Rejection

Answer 40

a claim that does not pass edits and is returned to the provider as rejected

Question 41

Reimburesement

Answer 41

payment from a third-party payer for services rendered to a patient covered by the payer’s health care plan

Question 42

State License Number

Answer 42

Identification number issued by a state to a physician who has been granted the right to practice in that state

Question 43

Usual, Customary, and Reasonable

Answer 43

UCR, used by third-party payers to establish a payment rate for a service in an area with the usual (standard fee in area), customary (standard fee by the physician), and reasonable (as determined by payer) rate