ACCEPTING ASSIGNMENT 1a

Transcription

1 ACCEPTING ASSIGNMENT 1a

2 WHEN A PHYSIAN AGREES TO TREAT MEDICAID PATIENTS ALSO AGREES TO ACCEPT THE ESTABLISHED MEDICAID PAYMENT FOR COVERED SERVICES. 1b

3 ADVANCE BENEFICIARY NOTICE - ABN 2a

4 FORM GIVEN TO PATIENTS BY PROVIDER WHEN A PROCEDURE/FEE FOR SERVICE WILL NOT BE COVERED BY MEDICARE 2b

5 ALLOWED CHARGE 3a

6 THE AMOUNT THAT IS THE MOST THE PAYER WILL PAY ANY PROVIDER FOR EACH PROCEDURE OR SERVICE. THE PAYERS PAYMENT IS BASED ON THIS ALLOWED CHARGE 3b

7 ASSIGNMENT OF BENEFITS 4a

8 A FORM THE PATIENT SIGNS "ASSIGNING" OR ALLOWING THEIR HEALTH INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE PROVIDER 4b

9 BENEFITS 5a

10 HEALTH CARE SERVICES YOU ARE ENTITILED TO 5b

11 BIRTHDAY RULE 6a

12 A RULE THAT STATES THE INSURANCE POLICY OF A POLICY HOLDER WHOSE BIRTHDAY COMES FIRST IN THE YEAR IS TO BE THE PRIMARY PAYER FOR ALL DEPENDENTS 6b

13 BLUE CROSS/BLUE SHIELD - BCBS 7a

14 BLUE CROSS BLUE SHIELD IS A NATION WIDE FERERATION OF NONPROFIT AND FOR PROFIT SERVICE ORGANIZATIONS THAT PROVIDE PREPAID HEALTH CARE SERVICES TO SUBSCRIBERS; BLUE CROSS COVERS MEDICAL BILLS (DOCTOR;S VISITS) AND BLUE SHIELD COVERS HOSPITALIZATION 7b

15 CAPITATION 8a

16 A PAYMENT STRUCTURE IN WHICH A HEALTH MAINTENENCE ORGANIZATION PREPAYS AN ANNUAL SET FEE PER PATIENT TO A PHYSICIAN 8b

17 CAPITATION (REIMBURSEMENT) 9a

18 THIS IS FIXED PREPAYMENT FOR EACH PLAN MEMBER IN CAPITATION CONTRACTS THAT IS DETERMINED BY THE MANAGED CARE PLAN THAT INITIATES CONTRACTS WITH PROVIDERS. THE PROVIDER LISTS THE SERVICES AND PROCEDURES THAT ARE COVERED BY THE CAP RATE. 9b

19 CHAMPUS 10a

20 CIVILIAN HEALTH AND MEDICAL PROGRAM FOR UNIFORMED SERVICES. 10b

21 CHAMPVA 11a

22 WHAT IS THE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE VETERANS ADMINISTRATION. A TYPE OF INSURANCE THAT COVERS THE HEALTH CARE EXPENSES OF DEPENDENTS OF VETERANS WITH SERVICE CONNECTED PERMANENT DISABILITIES. ALSO COVERS THE SURVIVING DEPENDENTS OF VETERANS WHO DIE IN THE LINE OF DUTY OR AS A RESULT OF A SERVICE CONNECTED DISABILITY 11b

23 CHARGE SLIP 12a

24 ORIGINAL RECORD OF SERVICES PERFORMED FOR A PATIENT AND THE CHARGES FOR THOSE SERVICES 12b

25 CLEARINGHOUSE 13a

26 A GROUP THAT TAKES NONSTANDARD MEDICAL BILLING SOFTWARE FORMATS AND TRANSLATES THEM INTO THE STANDARD EDI (ELECTRONIC DATA INTERCHANGE) FORMAT 13b

27 CMMS 14a

28 CENTERS FOR MEDICARE AND MEDICADE SERVICES IS A CONGRESSIONAL AGENCY DESIGNED TO HANDLE MEDICARE AND MEDICAID INSURANCE CLAIMS. IT WAS FORMERLY KNOWN AS THE HEALTH CARE FINANCING ADMINISTRATION (HCFA) 14b

29 CMS a

30 UNIVERSAL CLAIM FORM THAT IS SUBMITTED TO INSURANCE CARRIERS FOR PAYMENT OF THE INSURED'S MEDICAL FEES 15b

31 CO-PAYMENT 16a

32 AMOUNT A PATIENT HAS TO PAY AT TIME OF SERVICE DICTATED BY THE MANAGED CARE CONTRACT (HMO, PPO, OR POS) 16b

33 COINSURANCE 17a

34 A FIXED PERCENTAGE OF COVERED CHARGES PAID BY THE INSURED PERSON AFTER A DEDUCTABLE HAS BEEN MET 17b

35 CONTRACTED FEE SCHEDULE 18a

36 THIS IS WHEN PAYERS HAVE AN ESTABLISHED FIXED FEE SCHEDULE WITH PARTICIPATING PHYSICIANS THE TERMS FOR THE PLAN DETERMINE WHAT PERCENTAGE OF THE CHARGES IF ANY THE PATIENT OWES AND WHAT PERCENT THE PAYER COVERS. 18b

37 CONVERSION FACTOR - CF 19a

38 A NATIONALLY UNIFORM CONVERSION FACTOR IS A DOLLAR AMOUNT USED TO MULTIPLY THE RELATIVE VALUES TO PRODUCE A PAYMENT AMOUNT. IT IS USED BY MEDICARE TO MAKE ADJUSTMENTS ACCORDING TO CHANGES IN THE COST OF LIVING. 19b

39 CPT CODES 20a

40 COMMON PROCEDURAL TERMINOLOGY CODES - A SET OF NUMBERS/LETTERS THAT CORRESPOND TO COMMON PROCEDURE - THIS CODE IS ON THE ENCOUNTER FORM AND IS TRANSPOSED TO THE INSURANCE CLAIM FORM 20b

41 DEDUCTABLE 21a

42 A FIXED DOLLAR AMOUNT THAT MUST BE PAID (YEARLY) BY THE INSURED BEFORE EXPENSES ARE COVERED BY THE INSURANCE 21b

43 DEFINE MEDI/MEDI 22a

44 WHAT OLDER OR DISABLED PATIENTS WHO HAVE MEDICARE AND WHO CAN NOT PAY THE DIFFERENCE BETWEEN THE BILL AND WHAT MEDICARE PAYS MAY QUALIFY FOR MEDICARE MEDICAID. IN SUCH CASES MEDICARE IS THE PRIMARY PAYER.; MEDICAID PAYS THE REMAINDER OF THE BILL. THE PATIENT IS NEVER BILLED FOR A BALANCE UNLESS THE SERVICE IS A NON-COVERED SERVICE. 22b

45 DISABILITY INSURANCE 23a

46 THE INSURANCE THAT PROVIDES A MONTHLY, PREARRANGED PAYMENT TO AN INDIVIDUAL WHO CAN NOT WORK AS A RESULT OF AN INJURY ILLNESS OR DISABILITY 23b

47 ELECTIVE PROCEDURE 24a

48 A MEDICAL PROCEDURE THAT IS NOT REQUIRED TO SUSTAIN LIFE, BUT IS REQUESTED FOR PAYMENT TO THE THIRD PARTY PAYER BY THE PATIENT OR PHYSICIAN. SOME PROCEDURES ARE PAID FOR BY THIRD PARTY PAYERS WHEREAS OTHERS ARE NOT - USUALLY NEED PREAUTHORIZATION 24b

49 ELECTRONIC DATA INTERCHANGE - EDI 25a

50 WHAT IS ELECTRONIC DATA INTERCHANGE - THE TRANSMITTING OF ELECTRONIC MEDICAL INSURANCE CLAIMS FROM PROVIDERS TO PAYERS USING THE NECESSARY INFORMATION 25b

51 ENCOUNTER FORM OR SUPER- BILL 26a

52 A FORM THAT CAN BE USED AS THE ORIGINAL MEDICAL RECORD OF SERVICES PERFORMED FOR A PATIENT DURING AN ENCOUNTER OR OFFICE VISIT, AND CHARGES FOR THOSE SERVICES. THE FORM CAN ALSO BE USED AS A CHARGE SLIP, AS WELL AS AN INVOICE. IT CAN ALSO BE SUBMITTED WITH INSURANCE CLAIMS. 26b

53 EXCLUSION 27a

54 AN EXPENSE THAT IS NOT COVERED BY A PARTICULAR INSURANCE POLICY, SUCH AS EYE EXAMS OR DENTAL CARE 27b

55 EXPLANATION OF BENEFITS - EOB 28a

56 A FORM THAT EXPLAINS THE AMOUNT BILLED, AMOUNT ALLOWED BY INSURANCE CONTRACT, AMOUNT PAID BY INSURANCE CARRIER/COMPANY, AMOUNT OF SUSCRIBER'S/PATIENT'S LIABILITY, AND NOTATIONS OF ANY NON COVERED SERVICES WITH EXPLANATIONS. 28b

57 FEE FOR SERVICE 29a

58 FORMERLY INDEMNITY INSURANCE - A MAJOR TYPE OF HEALTH INSURANCE PLAN THAT REPAYS POLICY HOLDERS FOR THE COSTS OR A PERCENTAGE OF THE HEALTHCARE COSTS REDULTING FROM AN ILLNESS OR INJURY 29b

59 FEE SCHEDULE 30a

60 A LIST OF COMMON SERVICES AND PROCEDURES PERFORMED BY A PHYSICIAN AND THE CHARGES OF EACH 30b

61 FICA 31a

62 FEDERAL INSURANCE CONTRIBUTIONS ACT - MANAGED MEDICARE 31b

63 GEOGRAPHIC ADJUSTMENT FACTOR - GAF 32a

64 A GEOGRAPHIC ADJUSTMENT FACTOR IS USED TO ADJUST EACH RELATIVE VALUE TO REFLECT A GEOGRAPHICAL AREA'S RELATIVE COSTS SUCH AS OFFICE RENTS. 32b

65 HEALTH MAINTENANCE ORGANIZATION (HMO) 33a

66 HEALTH CARE ORGANIZATION THAT ESTABLISHES A NETWORK OF PROVIDERS WHO PROVIDE SPECIFIC SERVICES TO INDIVIDUALS AND THEIR DEPENDENTS WHO ARE ENROLLED IN THE PLAN. PHYSICIANS WHO ENROLL WITH AN HMO AGREE TO PROVIDE CERTAIN SERVICES IN EXCHANGE FOR A PREPAID FEE OR CAPITIATION PAYMENT. REFERRALS ARE NECESSARY TO SEE A SPECIALIST AND PREAUTHORIZATION IS REQUIRED FOR NON-EMERGENCY PROCEDURES 33b

67 ICD-9 OR ICD-10 CODES 34a

68 INTERNATIONAL CLASSIFICATION OF DISORDERS/DISEASES - A CODE OR SET OF NUMBERS/LETTERS THAT CORRESPOND TO PATIENT DIAGNOSIS - THEY ARE ON THE ENCOUNTER FORM AND USED FOR INSURANCE CLAIMS 34b

69 LIABILITY INSURANCE 35a

70 WHAT IS A TYPE OF INSURANCE THAT COVERS INJURIES CAUSED BY THE PROVIDER OR INJURIES THAT OCCURED ON THE PROVIDER'S PROPERTY 35b

71 LIFETIME MAXIMUM BENEFIT 36a

72 THE TOTAL SUM THAT A HEALTH PLAN WILL PAY OUT OVER THE PATIENT'S LIFE TIME 36b

73 MEDICAID 37a

74 WHAT IS A FEDERALLY FUNDED HEALTH COST ASSISTANCE PROGRAM FOR THE LOW INCOME, BLIND, AND DISABLED PATIENTS, FAMILIES RECIEVING AID TO DEPENDENT CHILDREN, FOSTER CHILDREN, AND CHILDREN WITH BIRTH DEFECTS. 37b

75 MEDICARE 38a

76 NATIONAL HEALTH INS PROGRAM FOR AMERICANS OVER AGE 65 OR WHO ARE DISABLED OR CHRONIC KIDNEY PATIENTS RECEIVING DIALYSIS 38b

77 MEDICARE ADVANTAGE PLANS 39a

78 PPO'S, HMO'S, PRIVATE FEE FOR SERVICE PLANS, AND MEDICARE MEDICAL SAVINGS ACCOUNTS THAT PROVIDE MEDICARE BENEFICIARIES WITH PLAN COVERAGE CHOICES IN ADDITION TO THE TRADITIONAL MEDICARE PLAN FOR A FEE 39b

79 MEDIGAP 40a

80 PRIVATE INSURANCE THAT MEDICARE BENEFICIARIES CAN PURCHASE TO REDUCE THE GAPS IN MEDICARE COVERAGE OR THE AMOUNT THEY WOULD HAVE TO PAY FROM THEIR OWN POCKETS AFTER RECEIVING MEDICARE BENEFITS 40b

81 PART A AND PART B MEDICARE 41a

82 PART A = HOSPITAL BENEFIT FINANCED THROUGH FICA -PAYS FOR UP TO A 90 DAY HOSPITALIZATION OR UP TO 60 DAYS SKILLED NURSING FACILITY PART B = COVERS A PORTION FOR OUTPATIENT PROCEDURES AND SUPPLIES. THIS PART IS VOLUNTARY. PREMIUM IS BASED ON INCOME AND INCREASES ANNUALLY. 41b

83 PART D MEDICARE 42a

84 PART OF MEDICARE THAT COVERS PRESCRIPTIONS (OPTIONAL FOR A FEE) 42b

85 PARTCIPATING PROVIDERS 43a

86 PROVIDERS (DOCTORS, SURGEONS, ETC) WHO ENROLL IN MANAGED CARE PLANS. THEY HAVE CONTRACTS WITH MANAGED CARE COMPANIES THAT STIPULATE THIER FEES 43b

87 PCP 44a

88 PRIMARY CARE PROVIDER - THE PATIENT'S MEDICAL DOCTOR 44b

89 POINT OF SERVICE - POS PLANS 45a

90 INSURANCE PLAN THAT COMBINES FEATURES OF HMO AND PPO - REFERRALS MAY BE GIVEN IN AND OUT OF NETWORK WHICH MAY REQUIRE A GREATER COPAYMENT BY THE PATIENT 45b

91 PRECERTIFICATION / PREAUTHORIZATION 46a

92 THE PROCESS OF THE PROVIDER CONTACTING THE INSURANCE PLAN TO SEE IF THE PROPOSED PROCEDURE IS COVERED UNDER THE PATIENTS INSURANCE PLAN 46b

93 PREFERRED PROVIDER ORGANIZATION (PPO) 47a

94 A MANAGED CARE PLAN THAT ESTABLISHES A NETWORK OF PROVIDERS TO PERFORM SERVICES FOR PLAN MEMBERS; REFERRALS NOT NEEDED TO SEE A SPECIALIST 47b

95 PREMIUM 48a

96 THE BASIC ANNUAL COST OF HEALTH CARE INSURANCE 48b

97 RAC PROGRAM 49a

98 WHAT IS THE RECOVERY AUDIT CONTRACTOR PROGRAM - THEY FIND WASTE FRAUD AND ABUSE IN MEDICARE. 49b

99 REFERRAL 50a

100 AN AUTHORIZATION FROM A MEDICAL PRACTICE FOR A PATIENT TO HAVE SPECIALIZED SERVICES PERFORMED BY ANOTHER PRACTICE (APPROVAL IS OFTEN REQUIRED FOR INSURANCE PURPOSES) 50b

101 REMITTANCE ADVICE - RA 51a

102 FORM USED BY MEDICARE THAT EXPLAINS THE BENEFITS (SIMILAR TO EOB FOR PRIVATE INSURANCE) 51b

103 RESOURSE BASED RELATIVE VALUE SCALE - RBRVS 52a

104 THE PAYMENT SYSTEM USED BY MEDICARE. IT ESTABLISHES THE RELATIVE VALUE UNITS FOR SERVICES, REPLACING THE PROVIDER CONSENSUS ON USUAL FEES 52b

105 RVU - RELATIVE VALUE UNIT 53a

106 THE NATIONALLY UNIFORM RELATIVE VALUE UNIT IS BASED ON THREE COST ELEMENTS. THE PHYSICIANS WORK, THE PRACTICE COST (OVERHEAD) AND THE COST OF MALPRACTICE INSURANCE. 53b

107 SCHIP 54a

108 THE STATE CHILDREN'S HEALTH INSURANCE PLAN. THIS PLAN ALLOWS STATES TO PROVIDE HEALTH COVERAGE TO UNINSURED CHILDREN AND FAMILIES WHOSE INCOMES ARE TOO HIGH TO QUALIFY FOR MEDICAID BUT ARE ALSO TOO LOW TO AFFORD PRIVATE INSURANCE. 54b

109 SNF 55a

110 SKILLED NURSING FACILITY 55b

111 TRICARE 56a

112 A GOVERNMENT PROGRAM THAT PROVIDES HEALTH CARE BENEFITS FOR DEPENDENTS OF MILITARY PERSONNEL AND MILITARY RETIREES. THIS IS NOT AN INSURANCE PLAN BUT RATHER A HEALTH CARE BENEFIT FOR FAMILIES OF UNIFORMED PERSONNEL AND RETIREES FROM UNIFORMED SERVICES. 56b

113 UCR - USUAL, CUSTOMARY, AND RESONABLE 57a

114 INSURANCE COMPANIES BASE THEIR PAYMENTS ON A USUAL, CUSTOMARY, AND REASONABLE FEE FOR A PARTICULAR SERVICE. USUAL - PHYSICIAN'S USUAL FEE FOR A GIVEN SERVICE; THE FEE MOST FREQUENTLY CHARGED FOR THE SERVICE. CUSTOMARY -RANGE OF USUAL FEES FOR A SERVICE CHARGED BY PHYSICIANS WITH SIMILAR TRAINING AND EXPERIENCE WHO PRACTICE IN THE SAME GEOGRAPHIC AREA. REASONABLE - FEE FOR EXCEPTIONALLY DIFFICULT OR COMPLICATED SERVICE OR A PROCEDURE THAT REQUIRES EXTRAORDINARY TIME OR EFFORT BY A PHYSICIAN 57b

115 WHAT ARE THE TYPES OF REIMBURSEMENT THIRD PARTY PAYERS USE. 58a

116 ALLOWED CHARGES CONTRACTED FEE SCHEDULE CAPITATION 58b

117 WHAT IS TRICARE FORMERLY KNOWN AS 59a

118 CHAMPUS 59b

119 WHO RUNS THE TRICARE 60a

120 THE DEFENCE DEPARTMENT 60b

121 WORKERS COMPENSATION INSURANCE 61a

122 THIS INSURANCE COVERS EMPLOYMENT RELATED ACCIDENTS OR DISEASES. FEDERAL LAW REQUIRES EMPLOYERS TO PURCHASE AND MAINTAIN A CERTAIN MINIMUM AMOUNT OF WORKERS COMP INS. 61b