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Facility-Based Reimbursement Issues > Reimbursement Terminology > Flashcards

Reimbursement Terminology Flashcards

1
Q

Advance Beneficiary Notice

A

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

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2
Q

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

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

A

Ancillary Service

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6
Q

APC

A

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

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7
Q

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

A

APC

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8
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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9
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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10
Q

Attending Physician

A

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

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11
Q

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

A

Attending Physician

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12
Q

Beneficiary

A

The person who benefits from insurance coverage

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13
Q

The person who benefits from insurance coverage

A

Beneficiary

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14
Q

Beneficiary is also known as…(5)

A

Subscriber
Dependent
Enrollee
Member
Participant

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15
Q

Birthday Rule

A

When both parents have insurance coverage, the parent with the birthday earliest in the year is the primary coverage for the dependent

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16
Q

When both parents have insurance coverage, the parent with the birthday earliest in the year is the primary coverage for the dependent

A

Birthday Rule

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17
Q

Certified Registered Nurse Anesthetist

A

An individual with specialized training and certification in nursing and anesthesia

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18
Q

An individual with specialized training and certification in nursing and anesthesia

A

Certified Registered Nurse Anesthetist

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19
Q

CRNA

A

Certified Registered Nurse Anesthetist

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20
Q

Charge Description Master

A

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

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21
Q

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

A

Charge Description Master

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22
Q

Co-Insurance

A

Cost-sharing of covered services

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23
Q

Cost-sharing of covered services

A

Co-Insurance

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24
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

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25
Q

Written strategy developed by medical facilities to ensure appropriate, consistent documentation within the medical record and ensure compliance with 3rd-party payer guidelines

A

Compliance Plan

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26
Q

Concurrent Care

A

More than 1 physician providing care to a patient at the same time

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27
Q

More than 1 physician providing care to a patient at the same time

A

Concurrent Care

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28
Q

Coordination of Benefits

A

Management of multiple 3rd-party payments to ensure overpayment does not occur

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29
Q

Management of multiple 3rd-party payments to ensure overpayment does not occur

A

Coordination of Benefits

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30
Q

COB

A

Coordination of Benefits

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31
Q

Co-Payment

A

Cost-sharing between beneficiary and payer

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32
Q

Cost-sharing between beneficiary and payer

A

Co-Payment

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33
Q

Correct Coding Initiative

A

Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment

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34
Q

Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment

A

Correct Coding Initiative

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35
Q

CCI

A

Correct Coding Initiative

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36
Q

Correct Coding Initiative is also known as…

A

NCCI (National Correct Coding Initiative)

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37
Q

Deductible

A

That portion of covered services paid by the beneficiary before 3rd-party payment begins

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38
Q

That portion of covered services paid by the beneficiary before 3rd-party payment begins

A

Deductible

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39
Q

Denial

A

Statement from the payer that reimbursement is denied

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40
Q

Statement from the payer that reimbursement is denied

A

Denial

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41
Q

Documentation

A

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

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42
Q

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

A

Documentation

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43
Q

Diagnosis-Related Groups

A

A case mix classification system established by CMS consisting of clauses of patients who are similar clinically and in consumption of hospital resources

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44
Q

A case mix classification system established by CMS consisting of clauses of patients who are similar clinically and in consumption of hospital resources

A

Diagnosis-Related Groups

45
Q

DRGs

A

Diagnosis-Related Groups

46
Q

Diagnosis-Related Groups was replaced with…

A

MS-DRGs

47
Q

Durable Medical Equipment

A

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

48
Q

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

A

Durable Medical Equipment

49
Q

DME

A

Durable Medical Equipment

50
Q

Electronic Data Interchange

A

Computerized submission of health care insurance information exchange

51
Q

Computerized submission of health care insurance information exchange

A

Electronic Data Interchange

52
Q

EDI

A

Electronic Data Interchange

53
Q

Employer Identification Number

A

An IRS-issued identification number used on tax documents

54
Q

An IRS-issued identification number used on tax documents

A

Employer Identification Number

55
Q

EIN

A

Employer Identification Number

56
Q

Encounter Form

A

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

57
Q

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

A

Encounter Form

58
Q

Explanation of Benefits

A

Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment

59
Q

Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment

A

Explanation of Benefits

60
Q

EOB

A

Explanation of Benefits

61
Q

Fee Schedule

A

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

62
Q

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

A

Fee Schedule

63
Q

Follow-Up Days

A

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

64
Q

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

A

Follow-Up Days

65
Q

FUD

A

Follow-Up Days

66
Q

Follow-Up Days also known as…(3)

A

Global Package
Global Days
Global Period

67
Q

Group Provider Number

A

Numeric designation for a group of providers that is used instead of the individual provider number

68
Q

Numeric designation for a group of providers that is used instead of the individual provider number

A

Group Provider Number

69
Q

GPN

A

Group Provider Number

70
Q

Hospital Payment Monitoring System

A

An inpatient PPS audit system used by CMS to reduce improper payments

71
Q

An inpatient PPS audit system used by CMS to reduce improper payments

A

Hospital Payment Monitoring System

72
Q

HPMS

A

Hospital Payment Monitoring System

73
Q

Invalid Claim

A

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

74
Q

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

A

Invalid Claim

75
Q

Inpatient

A

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

76
Q

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

A

Inpatient

77
Q

Medical Record

A

Documentation about the health care of a patient

78
Q

Documentation about the health care of a patient

A

Medical Record

79
Q

Medicare Administrative Contractors

A

MACs replaced Fiscal Intermediaries (FIs)

80
Q

MACs replaced Fiscal Intermediaries (FIs)

A

Medicare Administrative Contractors

81
Q

MACs

A

Medicare Administrative Contractors

82
Q

Medicare Severity Diagnosis-Related Groups

A

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

83
Q

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

A

Medicare Severity Diagnosis-Related Groups

84
Q

National Correct Coding Initiative

A

Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment

85
Q

Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment

A

National Correct Coding Initiative

86
Q

National Correct Coding Initiative is also known as…

A

CCI (Correct Coding Initiative)

87
Q

Noncovered Services

A

Any service not included by a 3rd-party payer in the list of services for which payment is made

88
Q

Any service not included by a 3rd-party payer in the list of services for which payment is made

A

Noncovered Services

89
Q

National Provider Identifier

A

10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers

90
Q

10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers

A

National Provider Identifier

91
Q

NPI

A

National Provider Identifier

92
Q

Hospital Outpatient

A

An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital

93
Q

An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital

A

Hospital Outpatient

94
Q

Prior Authorization

A

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

95
Q

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

A

Prior Authorization

96
Q

Prior Authorization is also known as…

A

Preauthorization

97
Q

Provider Identification Number

A

Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers

98
Q

Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers

A

Provider Identification Number

99
Q

PIN

A

Provider Identification Number

100
Q

UPIN

A

Provider Identification Number

101
Q

Rejection

A

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

102
Q

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

A

Rejection

103
Q

Reimbursement

A

A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan

104
Q

A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan

A

Reimbursement

105
Q

State License Number

A

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

106
Q

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

A

State License Number

107
Q

Usual, Customary, and Reasonable

A

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

108
Q

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

A

Usual, Customary, and Reasonable

Facility-Based Reimbursement Issues (3 decks)

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