Reimbursement Terminology Flashcards
Advance Beneficiary Notice
Notification in advance of services that Medicare may not pay for them, including the estimated cost to the patient
Notification in advance of services that Medicare may not pay for them, including the estimated cost to the patient
Advance Beneficiary Notice
ABN
Advance Beneficiary Notice
Ancillary Service
A service that is supportive of care of a patient, such as laboratory services
A service that is supportive of care of a patient, such as laboratory services
Ancillary Service
APC
A classification system used to group like services based upon clinical similarities and resources utilized
A classification system used to group like services based upon clinical similarities and resources utilized
APC
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
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
Assignment
Attending Physician
The physician legally responsible for oversight of an inpatient’s care
The physician legally responsible for oversight of an inpatient’s care
Attending Physician
Beneficiary
The person who benefits from insurance coverage
The person who benefits from insurance coverage
Beneficiary
Beneficiary is also known as…(5)
Subscriber
Dependent
Enrollee
Member
Participant
Birthday Rule
When both parents have insurance coverage, the parent with the birthday earliest in the year is the primary coverage for the dependent
When both parents have insurance coverage, the parent with the birthday earliest in the year is the primary coverage for the dependent
Birthday Rule
Certified Registered Nurse Anesthetist
An individual with specialized training and certification in nursing and anesthesia
An individual with specialized training and certification in nursing and anesthesia
Certified Registered Nurse Anesthetist
CRNA
Certified Registered Nurse Anesthetist
Charge Description Master
Record of services, procedures, supplies, and drugs with corresponding codes, descriptions, and charges billed
Record of services, procedures, supplies, and drugs with corresponding codes, descriptions, and charges billed
Charge Description Master
Co-Insurance
Cost-sharing of covered services
Cost-sharing of covered services
Co-Insurance
Compliance Plan
Written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with 3rd-party payer guidelines
Written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with 3rd-party payer guidelines
Compliance Plan
Concurrent Care
More than 1 physician providing care to a patient at the same time
More than 1 physician providing care to a patient at the same time
Concurrent Care
Coordination of Benefits
Management of multiple 3rd-party payments to ensure overpayment does not occur
Management of multiple 3rd-party payments to ensure overpayment does not occur
Coordination of Benefits
COB
Coordination of Benefits
Co-Payment
Cost-sharing between beneficiary and payer
Cost-sharing between beneficiary and payer
Co-Payment
Correct Coding Initiative
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
Correct Coding Initiative
CCI
Correct Coding Initiative
Correct Coding Initiative is also known as…
NCCI (National Correct Coding Initiative)
Deductible
That portion of covered services paid by the beneficiary before 3rd-party payment begins
That portion of covered services paid by the beneficiary before 3rd-party payment begins
Deductible
Denial
Statement from the payer that reimbursement is denied
Statement from the payer that reimbursement is denied
Denial
Documentation
Detailed chronology of facts and observations regarding a patient’s health
Detailed chronology of facts and observations regarding a patient’s health
Documentation
Diagnosis-Related Groups
A case mix classification system established by CMS consisting of clauses of patients who are similar clinically and in consumption of hospital resources
A case mix classification system established by CMS consisting of clauses of patients who are similar clinically and in consumption of hospital resources
Diagnosis-Related Groups
DRGs
Diagnosis-Related Groups
Diagnosis-Related Groups was replaced with…
MS-DRGs
Durable Medical Equipment
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
Durable Medical Equipment
DME
Durable Medical Equipment
Electronic Data Interchange
Computerized submission of health care insurance information exchange
Computerized submission of health care insurance information exchange
Electronic Data Interchange
EDI
Electronic Data Interchange
Employer Identification Number
An IRS-issued identification number used on tax documents
An IRS-issued identification number used on tax documents
Employer Identification Number
EIN
Employer Identification Number
Encounter Form
Medical document that contains information regarding a patient visit for health care services
Medical document that contains information regarding a patient visit for health care services
Encounter Form
Explanation of Benefits
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
Explanation of Benefits
EOB
Explanation of Benefits
Fee Schedule
Established list of payments for medical services, i.e., lab, physician services
Established list of payments for medical services, i.e., lab, physician services
Fee Schedule
Follow-Up Days
Established by 3rd-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
Established by 3rd-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
Follow-Up Days
FUD
Follow-Up Days
Follow-Up Days also known as…(3)
Global Package
Global Days
Global Period
Group Provider Number
Numeric designation for a group of providers that is used instead of the individual provider number
Numeric designation for a group of providers that is used instead of the individual provider number
Group Provider Number
GPN
Group Provider Number
Hospital Payment Monitoring System
An inpatient PPS audit system used by CMS to reduce improper payments
An inpatient PPS audit system used by CMS to reduce improper payments
Hospital Payment Monitoring System
HPMS
Hospital Payment Monitoring System
Invalid Claim
Claim that is missing necessary information and cannot be processed or paid
Claim that is missing necessary information and cannot be processed or paid
Invalid Claim
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
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
Inpatient
Medical Record
Documentation about the health care of a patient
Documentation about the health care of a patient
Medical Record
Medicare Administrative Contractors
MACs replaced Fiscal Intermediaries (FIs)
MACs replaced Fiscal Intermediaries (FIs)
Medicare Administrative Contractors
MACs
Medicare Administrative Contractors
Medicare Severity Diagnosis-Related Groups
MS-DRG, classifcation 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
MS-DRG, classifcation 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
Medicare Severity Diagnosis-Related Groups
National Correct Coding Initiative
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
National Correct Coding Initiative
National Correct Coding Initiative is also known as…
CCI (Correct Coding Initiative)
Noncovered Services
Any service not included by a 3rd-party payer in the list of services for which payment is made
Any service not included by a 3rd-party payer in the list of services for which payment is made
Noncovered Services
National Provider Identifier
10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers
10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers
National Provider Identifier
NPI
National Provider Identifier
Hospital Outpatient
An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital
An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital
Hospital Outpatient
Prior Authorization
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
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
Prior Authorization
Prior Authorization is also known as…
Preauthorization
Provider Identification Number
Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers
Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers
Provider Identification Number
PIN
Provider Identification Number
UPIN
Provider Identification Number
Rejection
A claim that does not pass edits and is returned to the provider as rejected
A claim that does not pass edits and is returned to the provider as rejected
Rejection
Reimbursement
A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan
A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan
Reimbursement
State License Number
Identification number, issued by state to a physician who has been granted the right to practice in that state
Identification number, issued by state to a physician who has been granted the right to practice in that state
State License Number
Usual, Customary, and Reasonable
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
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
Usual, Customary, and Reasonable
