TERMS

a statue prescribing a period of limitation for bringing of certain kinds of legal action

cpt code that includes a complete description of the procedure codes

a type of liability insurance that covers physicians and other health care professionals

involves linking insurance every procedure or service code reported on an insurance claim to a condition code

prior approval

also called transaction rule; a uniform language for electronic data interchange

also called coinsurance payment; the percentage the patient pays for covered services after the copayment has been met

documents patient care services that others who treat the patient have a source of information on which to base additional care & treatment

amount for which the patient is financially responsible before an insurance policy provides coverage

amount for which the patient is financially responsible before an insurance policy provides coverage

a person who signs a contract with a health insurance company & who, thus, owns, the health insurance policy the policy may include coverage

type of single payer system in which government owns and operates health care facility and providers receive salaries

a health insurance company that provides coverage, such as Bluecross Blueshield

voluntary process that a health care facility/organization undergoes to demonstrate that it has met standards beyond those required by law

provider accepts pre-established payments for providing healthcare services to enrollees over a period of time

prevents providers from discussing all treatment options with the patient wether or not the plan would provide reimbursement for services

primary care provider for essential healthcare services at the lowest possible cost avoiding nonessential care and referring to specialist

provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts)

the maximum amount the payer will reimburse for each procedure or service, according to the patients policy.

the provider receives reimbursement directly from the payer

the person eligible to receive health care benefits

determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan

judical dispute resolution process in which an appeals board makes a final determination

documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment

a correctly completed standardized claim ex CMS 1500

performs centralized claims processing for providers and health plans

assigning lower level codes than documented in the record

person responsible for paying healthcare fees

legal action to recover a debt, usually a last resort for a medical practice

term used for an encounter form in the physicians office

submitting multiple cpt codes when one code should be submitted

assignment of an ICD-10-cm diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimburse

individuals entitled to medicare and eligible for some type of medicaid benefit