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Physician-Based Reimbursement Issues > Reimbursement Terminology > Flashcards

Reimbursement Terminology Flashcards

1
Q

Advance Beneficiary Notice

A

Notification in advance of services that Medicare probably will not pay for and the estimated cost to patient

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2
Q

Notification in advance of services that Medicare probably will not pay for and the estimated cost to patient

A

Advance Beneficiary Notice

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3
Q

ABN

A

Advance Beneficiary Notice

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4
Q

Ancillary Service

A

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

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5
Q

What is formerly WOL, Waiver of Liability?

A

Advance Beneficiary Notice

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6
Q

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

A

Ancillary Service

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7
Q

Assignment

A

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

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8
Q

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

A

Assignment

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9
Q

Attending Physician

A

The physician legally responsible for oversight of an inpatient’s care (in residency programs, the teaching physician that monitors the resident’s work)

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10
Q

The physician legally responsible for oversight of an inpatient’s care (in residency programs, the teaching physician that monitors the resident’s work)

A

Attending Physician

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11
Q

Beneficiary

A

The person who benefits from insurance coverage

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12
Q

The person who benefits from insurance coverage

A

Beneficiary

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13
Q

The Beneficiary is also know as:
(5)

A

Subscriber
Dependent
Enrollee
Member
Participant

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14
Q

Birthday Rule

A

When both parents have insurance coverage, the parent with the birthday earlier in the year carries the primary coverage for a dependent

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15
Q

When both parents have insurance coverage, the parent with the birthday earlier in the year carries the primary coverage for a dependent

A

Birthday Rule

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16
Q

Certified Registered Nurse Anesthetist

A

An individual with specialized training and certification in nursing and anesthesia administration

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17
Q

An individual with specialized training and certification in nursing and anesthesia administration

A

Certified Registered Nurse Anesthetist

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18
Q

CRNA

A

Certified Registered Nurse Anesthetist

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19
Q

“Clean Claim”

A

A properly completed claim submitted to a payer with all data fields containing current and accurate information and submitted within the timely filing period required by the insurer

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20
Q

A properly completed claim submitted to a payer with all data fields containing current and accurate information and submitted within the timely filing period required by the insurer

A

“Clean Claim”

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21
Q

Coinsurance

A

Cost-sharing of covered services

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22
Q

Cost-sharing of covered services

A

Coinsurance

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23
Q

Compliance Plan

A

Written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with 3rd-party payer guidelines and the Office of the Inspector General (OIG) Workplan guidelines

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24
Q

Written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with 3rd-party payer guidelines and the Office of the Inspector General (OIG) Workplan guidelines

A

Compliance Plan

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25
Concurrent Care
More than 1 physician providing care to a patient at the same time
26
More than 1 physician providing care to a patient at the same time
Concurrent Care
27
Coordination of Benefits
Management of multiple 3rd-payments to ensure overpayment does not occur
28
Management of multiple 3rd-payments to ensure overpayment does not occur
Coordination of Benefits
29
COB
Coordination of Benefits
30
Co-Payment
Cost-sharing between beneficiary and payer
31
Cost-sharing between beneficiary and payer
Co-Payment
32
Deductible
That portion of covered services paid by the beneficiary before 3rd-party payment begins
33
That portion of covered services paid by the beneficiary before 3rd-party payment begins
Deductible
34
Denial
Statement from a payer that coverage is denied
35
Statement from a payer that coverage is denied
Denial
36
Documentation
Detailed chronology of facts and observations, procedures, services, and diagnoses relative to the patient’s health
37
Detailed chronology of facts and observations, procedures, services, and diagnoses relative to the patient’s health
Documentation
38
Durable Medical Equipment
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
39
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
Durable Medical Equipment
40
DME
Durable Medical Equipment
41
Electronic Data Interchange
Computerized submission of healthcare insurance information exchange
42
Computerized submission of healthcare insurance information exchange
Electronic Data Interchange
43
EDI
Electronic Data Interchange
44
Employer Identification Number
IRS-issued identification number used on tax documents
45
IRS-issued identification number used on tax documents
Employer Identification Number
46
EIN
Employer Identification Number
47
Encounter Form Superbill
Medical document that contains information regarding a patient visit for health care services, can serve as a billing and/or coding document
48
Medical document that contains information regarding a patient visit for health care services, can serve as a billing and/or coding document
Encounter Form Superbill
49
Explanation of Benefits
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
50
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
Explanation of Benefits
51
EOB
Explanation of Benefits
52
EOMB
Explanation of Benefits
53
Fee Schedule
List of established payment for medical services arranged by CPT and HCPCS codes
54
List of established payment for medical services arranged by CPT and HCPCS codes
Fee Schedule
55
Follow-Up Days
Established by 3rd-party payers and listing the number of days after a procedure for which a provider must provide services to a patient for no fee
56
Established by 3rd-party payers and listing the number of days after a procedure for which a provider must provide services to a patient for no fee
Follow-Up Days
57
FUD
Follow-Up Days
58
Follow-Up Days is also know as… (3)
Global Days Global Package Global Period
59
Group Provider Number
A numeric designation for a group of providers that is used instead of the individual provider number
60
A numeric designation for a group of providers that is used instead of the individual provider number
Group Provider Number
61
GPN
Group Provider Number
62
HMO
Health Maintenance Organization
63
Invalid Claim
Claim that is missing necessary information and cannot be processed or paid
64
Claim that is missing necessary information and cannot be processed or paid
Invalid Claim
65
Medical Record
Documentation about the health care of a patient to include diagnoses, services, and procedures rendered
66
Documentation about the health care of a patient to include diagnoses, services, and procedures rendered
Medical Record
67
National Provider Identifier
10-digit number assigned to provider by CMS and National Plan and Provider Enumeration System (NPPES) and used for identification purposes when submitting services to 3rd-party payers
68
10-digit number assigned to provider by CMS and National Plan and Provider Enumeration System (NPPES) and used for identification purposes when submitting services to 3rd-party payers
National Provider Identifier
69
NPI
National Provider Identifier
70
Noncovered Services
Any service not included by a 3rd-party payer in the list of services for which payment is made
71
Any service not included by a 3rd-party payer in the list of services for which payment is made
Noncovered Services
72
Point of Service
A plan in which either an in-network or out-of-network provider may be used with a higher rate paid to in-network providers
73
A plan in which either an in-network or out-of-network provider may be used with a higher rate paid to in-network providers
Point of Service
74
POS
Point of Service
75
Preferred Provider Organization
Providers form a network to offer health care services to a group
76
Providers form a network to offer health care services to a group
Preferred Provider Organization
77
PPO
Preferred Provider Organization
78
Prior Authorization
Is a requirement by the payer to receive written permission prior to patient services in order to be considered for payment by the payer
79
Is a requirement by the payer to receive written permission prior to patient services in order to be considered for payment by the payer
Prior Authorization
80
Prior Authorization is also known as…
Preauthorization
81
Provider Identification Number
A number assigned by a 3rd-party payer to providers to be used for identification purposes when submitting claims
82
A number assigned by a 3rd-party payer to providers to be used for identification purposes when submitting claims
Provider Identification Number
83
PIN
Provider Identification Number
84
Reimbursement
Payment from a 3rd-party payer for services rendered to a patient covered by the payer’s health care plan
85
Payment from a 3rd-party payer for services rendered to a patient covered by the payer’s health care plan
Reimbursement
86
Rejection/Denial
A claim that did not pass the edits and is returned to the provider as rejected
87
A claim that did not pass the edits and is returned to the provider as rejected
Rejection/Denial
88
Resource-Based Relative Value Scale
A list of physician services with assigned units of monetary value
89
A list of physician services with assigned units of monetary value
Resource-Based Relative Value Scale
90
RBRVS
Resource-Based Relative Value Scale
91
State License Number
Identification number issued by a state to a physician who has been granted the right to practice in that state
92
Identification number issued by a state to a physician who has been granted the right to practice in that state
State License Number
93
UPIN
Unique provider identification number was replaced by the NPI
94
Unique provider identification number was replaced by the NPI
UPIN
95
Usual, Customary, and Reasonable
Used by some 3rd-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) fee amounts
96
Used by some 3rd-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) fee amounts
Usual, Customary, and Reasonable
97
UCR
Usual, Customary, and Reasonable
98
HIPAA
Health Insurance Portability and Accountability Act
99
PDP
Prescription Drug Plan Medicare Part D
100
MAO
Medicare Advantage Organizations-combines Parts A & B Medicare Part C
101
LCDs
Local Coverage Determinations
102
NCDs
National Coverage Determinations

Physician-Based Reimbursement Issues (3 decks)

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