Reimbursement Terminology Flashcards
Advance Beneficiary Notice
ABN, notification in advance of services that Medicare may not pay for them, including the estimated cost to the patient
Ancillary Service
a service that is supportive of care of a patient, such as lab services
APC
a classification system used to group like services based upon clinical similarities and resources utilized
Assignment
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
Attending Physician
the physician legally responsible for oversight of an inpatient’s care
Beneficiary
the person who benefits from insurance coverage, also known as subscriber, dependent, enrollee, member, or participant
Birthday Rule
when both parents have insurance coverage, the patient with the birthday earliest in the year is the primary coverage for a dependant
Certified Registered Nurse Anesthetist
CRNA, an individual with specialized training and certification in nursing and anesthesia
Charge Description Master
record of services, procedures, supplies, and drugs with corresponding codes, descriptions, and charges billed
Co-Insurance
cost-sharing of covered services
Compliance Plan
written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with third-party payer guidelines
Concurrent Care
more than one physician providing care to a patient at the same time
Coordination of Benefits
COB, management of multiple third-party payments to ensure overpayment does not occur
Co-Payment
cost-sharing between beneficiary and payer
Correct Coding Initiative
CCI, developed by CMS to control improper unbundling of CPT codes leading to inapproproate payment; also known as NCCI (National Correct Coding Initiative)
Deductible
that portion of covered services paid by the beneficiary before third-party payment begins
Denial
statement from the payer that reimbursement is denied
Documentation
detailed chronology of facts and observations regarding a patient’s health
DRGs
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
Durable Medical Equipment
DME, medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
Electronic Data Interchange
EDI, computerized submission of health care insurance information exchange
Employer Idenitification Number
EIN, an Internal Revenue Service (IRS)- issued identification number used on tax documents
Encounter Form
medical document that contains information regarding a patient visit for health care services
Explanation of Benefits
EOB, written, detailed listing of medical service payments by third-party payer to inform beneficiary and provider of payment
Fee Schedule
established list of payments for medical services, i.e. lab, physician services
Follow-Up Days
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)
Group Provider Number
GPN, numeric designation for a group of providers that is used instead of the individual provider number
Hospital Payment Monitoring System
HPMS, an inpatient PPS audit system used by CMS to reduce improper payments
Invalid Claim
claim that is missing necessary information and cannot be processed or paid
Inpatient
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
Medical Record
documentation about the health care of a patient
Medicare Administrative Contractors
MACs replaced Fiscal Intermediaries (FIs)
Medicare Severity Diagnosis-Related Groups
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
National Correct Coding Initiative
developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment; also known as CCI (Correct Coding Initiative
Noncovered services
any service not included by a third-party payer in the list of services for which payment is made
National Provider Identifier
NPI, a 10-digit number assigned to provider and used for identification purposes when submitting services to third-party payers
Hospital Outpatient
an individual who is not an inpatient of a hospital but who is registered as an outpatient at the hospital
Prior Authorization
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
Provider Identification Number
PIN or UPIN, assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers
Rejection
a claim that does not pass edits and is returned to the provider as rejected
Reimburesement
payment from a third-party payer for services rendered to a patient covered by the payer’s health care plan
State License Number
Identification number issued by a state to a physician who has been granted the right to practice in that state
Usual, Customary, and Reasonable
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
