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Acceptance of assignment
Under governmental health care programs, a physician's agreement to accept the allowed charge as payment in full.
Acute
Refers to a medical condition that runs a short but relatively severe course. May also refer to a sudden exacerbation of a chronic condition.
Advance beneficiary notice
Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program.
Allowed charge
The maximum charge that a health plan pays for a specific service or procedure; also called allowable charge, maximum fee, and other terms.
Ancillary services
Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests.
Appeal
Request for more payment made by asking for a review of an insurance claim that has been paid or denied by and insurance company.
Applicant
Person applying for insurance coverage
Approved charges
Fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed. The patient may or may not be responsible for the difference.
Assignment of benefits
Permission granted by the insured that allows the insurance company to send the amount paid directly to the physician, health care provider, hospital, or nursing facility. If the patient does not sign the assignment of benefits, the insurance benefit check goes to the policyholder.
Attending physician
Medical staff member who is legally responsible for the care and treatment given to a patient.
Benefits
The amount of money a health plan pays for services covered in an insurance policy.
Benefit period
Period of time for which payments for Medicare inpatient hospital benefits are available. A benefit period begins the first day an enrollee is given inpatient hospital care (nursing care or rehabilitation services) by qualified provider and ends when the enrollee has not been inpatient for 60 consecutive days. For disability insurance, it is the maximum amount of time that benefits will be paid to the injured or ill person for a disability.
Bilateral
When coding surgical procedures, this term refers to both sides of the body.
Birthday rule
The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary
Capitation
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.
Catastrophic cap
Under limit that an active-duty family has to pay under TRICARE Standard-covered medical bills in any fiscal year.
Categorically needy
Aged, blind, or families and children who meet financial eligibility requirements for Aid to Families with Dependent Children, Supplemental Security Income, or and optional state supplement.
Center for Medicare and Medicaid Services
The governmental department that runs Medical and other governmental health programs.
Chief complaint
Patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.
Chronic
Medical condition persisting over a long period of time.
Claim
Request for payment of a covered medical expense, sent to the insurance company, may be submitted by the insured or by the agency or individual that provided the medical care.
Coexisting condition
Additional illness that either has an effect on the patient's primary illness or is also treated during the encounter.
Coinsurance
Portion of covered charges the insured must pay beyond any applicable deductible. It is a specified percentage of each fee for a covered service the patient must pay to provider (for Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible).
Compliance program
A management plan composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical record keeping that fulfills official requirement.
Consultation
Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem.
Coordination of benefits
Health insurance policy clause that applies to an individual covered by more than one medical insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
Copayment
Provision in an insurance policy requiring the policy holder or patient to pay a specified dollar amount to a health care provider for each visit or medical service they receive.
Crossover claim
Claim for services to a Medicare/Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer.
Deductible
Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually annual amount per individual or family
Dependent
Person(s) financially supported by the insured; ie spouse, children, and others as described in the policy.
Durable Medical equipment
Medicare term for reusable physical supplies such as wheelchairs and hospital beds that are ordered by the provider for use in the home; reported with HPCPS Level II codes.
Early and Periodic Screening Diagnosis, and Treatment
Medicaid's prevention, early detection, and treatment program for eligible children under the the age of 21.
Emancipated Minor
Person younger than 18 years of age who lives independently, is totally self-supporting, is married or divorced, is a parent even if not married, or is in the military and possesses decision-making rights.
Eponym
A condition or procedure named after a person or place.
Established Patient
Individual who has received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
Excluded service
A service specified in a medical insurance contract as not covered.
Explanation of benefits
A recap sheet that accompanies an insurance checks showing the breakdown and explanation of payments on a claim.
Fee-for-service
Method of charging under which a provider's payment is based on each service performed.
Fee schedule
A list of charges for services performed
Fiscal intermediary
A governmental contractor that processes claims for governmental programs. (For Medicare the fiscal intermediary processed Part A claims.
Formulary
A list of a health plan's selected drugs and their proper dosages; often a plan pays only for the drugs it lists.
Group contract
Health insurance policy purchased by an organization or corporation that covers a defined group of individuals and eligible dependents; e.g the employees of an organization/corporation or members of a union or professional association.
Guarantor
An individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatment constitutes an expressed promise.
Major Medical
Health insurance policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury.
Managed Care
A system that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
Medical necessity
Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient's symptoms and diagnosis.
Medically indigent
A classification of Medicaid recipient that includes people who can pay for basic living expenses but cannot pay high medical bills.
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Medigap insurance
An insurance plan offered by a federally approved private insurance carrier designed to supplement Medicare coverage.
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