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Advance Beneficiary Notice (ABN): document used to notify a Medicare beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay for the service they are going to be provided. Beneficiaries are required to sign this document if they wish to have the service with the understanding that they will be responsible for payment.
Outstanding Check: A check that has been written and recorded in the checkbook but has not yet cleared the bank. It remains unpaid and is not reflected in the bank statement balance.
Explanation of Benefits (EOB): printed description of the benefits provided by the insurer to the beneficiary; provides information to the patient about how an insurance claim from a health provider (such as a physician or hospital) was paid on their behalf.
Coinsurance: percentage that a patient is responsible for paying for each service after the deductible has been met.
Exclusive Provider Organization (EPO): EPOs are like HMOs in that patients must use their EPO’s provider network when receiving care. There is no partial coverage for out-of-network care.
Health Maintenance Organization (HMO): a type of managed care operation that is typically set up as a for-profit corporation with salaried employees; group insurance that entitles members to services provided by participating hospitals, clinics, and providers.
Preauthorization: prior approval of insurance coverage and necessity of procedure; refers to obtaining plan approval for services prior to the patient receiving them; relates not only to whether the services are covered but also whether the proposed treatment is medically necessary (see Figure 24–12). See Procedure 24–2 for steps in obtaining preauthorization for a procedure.
Third Party Liability (TPL): refers to the legal obligation of third parties (e.g., certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a state plan. Table 24–1 provides examples of third parties that may be liable to pay for services.
Third Party Reimbursement: phrase coined to indicate payment of services rendered by someone other than the patient. With this came the need for some form of paperwork as the means of reporting the health care provided to the source of payment, and the claim form was developed. Today, the most common third-party payers are federal and state agencies, insurance companies, and workers’ compensation.
Subscriber: the person who has been insured; an insurance policyholder.
Medicaid: joint funding program by federal and state governments (excluding Arizona) for the medical care of low-income patients on public assistance.
Medicare: federal program for providing health care coverage for individuals over the age of 65 or those who are disabled.
Indemnity-Type Insurance: type of insurance plan that has the least amount of structural guidelines for patients to follow. Patients are able to see the provider of their choice without having to deal with listings of participating providers and other managed care guidelines.
Preferred Provider Organization (PPO): organization of physicians who network together to offer discounts to purchasers of health care insurance.
Comorbidity: condition that exists along with the primary diagnosis of a patient.
Current Procedural Terminology (CPT): numerical listing of procedures performed in medical practice; a standardized identification of procedures. Published by the American Medical Association.
HCPCS Level II Codes: Healthcare Common Procedure Coding System (HCPCS) Level II codes are alphanumeric codes used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services, durable medical equipment, prosthetics, and medications. These codes are maintained by the Centers for Medicare & Medicaid Services (CMS).
Reconciling: process to bring checkbook and bank statement into agreement.
National Provider Identifier (NPI): the name of the standard unique health identifier for health care providers.
Secondary Insurance: exists when a patient is covered under more than one insurance plan; charges are first submitted to the primary carrier, and any charges not covered are then submitted to the secondary carrier.
Crossover Claim: A crossover claim is a type of insurance claim that is automatically transferred from Medicare to a secondary payer (such as Medicaid or a Medigap plan) after Medicare has processed it. This process ensures that the secondary insurer receives the claim without requiring the provider or patient to resubmit it manually
Clearinghouse: In medical billing, a clearinghouse acts as an intermediary between healthcare providers and insurance payers. It receives electronic claims from providers, checks them for errors, formats them according to payer requirements, and then forwards them to the appropriate insurance company. This process helps ensure clean and accurate claim submissions
Centers for Medicare and Medicaid Services (CMS): previously known as the Health Care Financing Administration (HCFA), CMS is the federal agency within the U.S. Department of Health and Human Services (HHS) responsible for administration of several key federal health care programs (Medicare and Medicaid).
Stop Payment: a method by which the maker of a check may stop payment of a check(s) written.
International Classification of Diseases (ICD): comprehensive listing of diseases and disorders of the human body. Effective October 1, 2015, ICD-9 was replaced with ICD-10. ICD-10-CM codes describe the disease or condition presented by the patient; use of these codes establishes the medical necessity for the services and procedures provided to the patient.