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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
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
26
Concurrent Care
More than 1 physician providing care to a patient at the same time
27
More than 1 physician providing care to a patient at the same time
Concurrent Care
28
Coordination of Benefits
Management of multiple 3rd-party payments to ensure overpayment does not occur
29
Management of multiple 3rd-party payments to ensure overpayment does not occur
Coordination of Benefits
30
COB
Coordination of Benefits
31
Co-Payment
Cost-sharing between beneficiary and payer
32
Cost-sharing between beneficiary and payer
Co-Payment
33
Correct Coding Initiative
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
34
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
Correct Coding Initiative
35
CCI
Correct Coding Initiative
36
Correct Coding Initiative is also known as…
NCCI (National Correct Coding Initiative)
37
Deductible
That portion of covered services paid by the beneficiary before 3rd-party payment begins
38
That portion of covered services paid by the beneficiary before 3rd-party payment begins
Deductible
39
Denial
Statement from the payer that reimbursement is denied
40
Statement from the payer that reimbursement is denied
Denial
41
Documentation
Detailed chronology of facts and observations regarding a patient’s health
42
Detailed chronology of facts and observations regarding a patient’s health
Documentation
43
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
44
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
45
DRGs
Diagnosis-Related Groups
46
Diagnosis-Related Groups was replaced with…
MS-DRGs
47
Durable Medical Equipment
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
48
Medically related equipment that is not disposable, such as wheelchairs, crutches, and vaporizers
Durable Medical Equipment
49
DME
Durable Medical Equipment
50
Electronic Data Interchange
Computerized submission of health care insurance information exchange
51
Computerized submission of health care insurance information exchange
Electronic Data Interchange
52
EDI
Electronic Data Interchange
53
Employer Identification Number
An IRS-issued identification number used on tax documents
54
An IRS-issued identification number used on tax documents
Employer Identification Number
55
EIN
Employer Identification Number
56
Encounter Form
Medical document that contains information regarding a patient visit for health care services
57
Medical document that contains information regarding a patient visit for health care services
Encounter Form
58
Explanation of Benefits
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
59
Written, detailed listing of medical service payments by 3rd-party payer to inform beneficiary and provider of payment
Explanation of Benefits
60
EOB
Explanation of Benefits
61
Fee Schedule
Established list of payments for medical services, i.e., lab, physician services
62
Established list of payments for medical services, i.e., lab, physician services
Fee Schedule
63
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
64
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
65
FUD
Follow-Up Days
66
Follow-Up Days also known as…(3)
Global Package Global Days Global Period
67
Group Provider Number
Numeric designation for a group of providers that is used instead of the individual provider number
68
Numeric designation for a group of providers that is used instead of the individual provider number
Group Provider Number
69
GPN
Group Provider Number
70
Hospital Payment Monitoring System
An inpatient PPS audit system used by CMS to reduce improper payments
71
An inpatient PPS audit system used by CMS to reduce improper payments
Hospital Payment Monitoring System
72
HPMS
Hospital Payment Monitoring System
73
Invalid Claim
Claim that is missing necessary information and cannot be processed or paid
74
Claim that is missing necessary information and cannot be processed or paid
Invalid Claim
75
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
76
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
77
Medical Record
Documentation about the health care of a patient
78
Documentation about the health care of a patient
Medical Record
79
Medicare Administrative Contractors
MACs replaced Fiscal Intermediaries (FIs)
80
MACs replaced Fiscal Intermediaries (FIs)
Medicare Administrative Contractors
81
MACs
Medicare Administrative Contractors
82
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
83
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
84
National Correct Coding Initiative
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
85
Developed by CMS to control improper unbundling of CPT codes leading to inappropriate payment
National Correct Coding Initiative
86
National Correct Coding Initiative is also known as…
CCI (Correct Coding Initiative)
87
Noncovered Services
Any service not included by a 3rd-party payer in the list of services for which payment is made
88
Any service not included by a 3rd-party payer in the list of services for which payment is made
Noncovered Services
89
National Provider Identifier
10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers
90
10-digit number assigned to provider and used in identification purposes when submitting services to 3rd-party payers
National Provider Identifier
91
NPI
National Provider Identifier
92
Hospital Outpatient
An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital
93
An individual who is not an inpatient at a hospital, but who is registered as an outpatient in the hospital
Hospital Outpatient
94
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
95
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
96
Prior Authorization is also known as…
Preauthorization
97
Provider Identification Number
Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers
98
Assigned by the third-party payer to providers to be used for identification purposes, when submitting services to third-party payers
Provider Identification Number
99
PIN
Provider Identification Number
100
UPIN
Provider Identification Number
101
Rejection
A claim that does not pass edits and is returned to the provider as rejected
102
A claim that does not pass edits and is returned to the provider as rejected
Rejection
103
Reimbursement
A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan
104
A payment from a third-party payer for services rendered to a patient covered by the payers healthcare plan
Reimbursement
105
State License Number
Identification number, issued by state to a physician who has been granted the right to practice in that state
106
Identification number, issued by state to a physician who has been granted the right to practice in that state
State License Number
107
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
108
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

Facility-Based Reimbursement Issues (3 decks)

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