GLOSSARY OF HEALTH INSURANCE TERMS
From Understanding Health Insurance by JoAnn C. Rowell, Delmar Publishers 4th ed 1996
active duty personnel: Government service personnel on current assignment with one of the uniformed services.
admitting physician: The physician who arranged for The patient's admission to the hospital but who does not necessarily have control over the patient's care (See attending physician.)
adult primary policy: The patient is the policyholder or subscriber; the person responsible for purchasing the policy.
adult secondary policy: The patient is listed as a dependent on a second full benefit policy.
adverse effect: A pathological reaction following the ingestion of or exposure to drugs or other chemical substances. These effects may result from the cumulative effects of a drug/ substance, the patient's hypersensitivity to the substance, unexpected side effects, or an interaction between two or more prescribed drugs.
Aid to Families with Dependent Children (AFDC) A welfare program covering pregnant women and young children who are members of households where income falls below the poverty level.
allowed charge: The maximum amount, according to the individual policy, that insurance will pay for each procedure or service performed.
a la carte billing: The breaking down of an integrated major surgical package into various components for the purpose of differential coding and obtaining a higher reimbursement.
allowed fee: See allowed charge.
*Ambulatory Patient Group (APG): The prospective payments of outpatient claims based on the reason for the encounter with the patient.
Ambulatory Surgical Center (ASC) An independent surgical facility certified and accredited by state health departments for the purpose of performing surgery on patients who are expected to be discharged the same day surgery is performed. ASCs performing surgery on Medicare patients must also be accredited with HCFA.
American Academy of Procedural Coders (AAPC): A Salt Lake City-based organization established in 1988 to ensure professional standards for procedural coders and to increase recognition within the health care industry of the coders and the professional services they perform.
American Hospital Association (AHA): Professional organization promoting the ideal and functions of acute care hospitals in the United States.
American Medical Association (AMA): The largest United States professional association of physicians, and publisher of Physician's Current Terminology, Fourth Edition, (CPT-4).
approved fee or rate: See allowed charge.
Armed Forces: The Army, Navy, Coast Guard, Air Force, and Marines
*assignment of insurance benefits: An authorization granted by the patient to allow the insurance company to pay claim benefits directly to the provider of care. It is to the provider's benefit to have the patient sign the "assignment of benefits" statement on each claim form. All benefits due to the provider will be mailed directly to the provider rather than to the patient.
attending physician: The physician in charge of the patient's care; this physician may or may not be the physician who admitted the patient to the hospital.
Authorization To Release Medical Information: Written permission given by the patient (or his representative) authorizing the provider of care to release treatment and diagnostic information to a specified party.
balance billing: Charging the patient for the difference between the physician's fee and the insurance carrier's allowed fee.
*basic coverage: (Blue Cross/Blue Shield) Insurance coverage limited to basic inpatient medical and diagnostic care, and both inpatient and outpatient surgery services.
BC/BS Medicare Supplemental Plan: A Blue Cross/Blue Shield policy designed to augment the patient's Medicare benefits. (Also may be known as a BC/BS Medigap plan if the plan meets federal Medigap standards.)
beneficiary: A person eligible to receive the benefits of a specific policy or program.
*benefit: An amount payable by an insurance company to the insured or the insured's designated health care provider for covered medical expenses.
benefit period: A Medicare designation for the period of time covered by the inpatient deductible. A benefit period starts with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days. (Also known as "spell of illness.")
benign: A tumor that is noninvasive (not affecting deeper tissue), localized, and nonspreading.
billing entity: A legal business name of a practice or organization.
Birthday Rule: Guideline for the designation of the primary insurance policy when dependents are concurrently enrolled in two or more policies. The rule states the following: The primary policy is the one taken out by the policyholder with the earliest birthday occur ring in the calendar year. In cases where the birthdays of the policyholders occur on the same day, the policy that has been in effect the longest is considered primary. The year of birth does not enter into this factor.
BlueCard Program: A BC/BS Association program that eases the processing of claims from PAR and PPN providers when they provide medical services to BC/BS patients enrolled in plans outside the health care provider's local service area. This program was formerly known as the "Out-Of-Area Program."
Blue Cross (BC): A medical insurance corporation organized for the purpose of offering pre paid hospital care plans to people living and working in a specific geographic region.
Blue Shield (BS): A medical insurance corporation organized for the purpose of offering pre paid medical and surgical care plans to people living and working in a specific geographic region.
breach of confidentiality: Unauthorized release of confidential patient information to a third party.
cancer in situ. See carcinoma in situ
capitated payments: Payments made to health care providers who are staff members of HMOs where the provider is paid a contractually agreed upon per capita fee for all services pro vided to an enrollee served regardless of the actual number or nature of the services provided.
capitation: A reimbursement system used by HMOs and some other managed care plans to pay the health care provider a fixed fee on a per capita basis that has no relationship to type of services performed or the number of services each patient receives.
carcinoma In situ: A malignant tumor that is localized, circumscribed, and noninvasive (not affecting deeper tissue).
Care/Caid Claim: Combined Medicare/ Medicaid claim care plan oversight service: A CPT evaluation and management service for the purpose of reporting the physician's time spent coordinating multidisciplinary patient care plans, and integrating or adjusting the patient's medical treatment plans.
carrier: The insurance company; the insurer
case management service: A CPT evaluation and management service for the process in which the attending physician or agent coordinates the care given to a patient by other health care providers and/or community organizations.
case manager: A nurse or other medically trained person who coordinates the care of patients with long term chronic conditions.
cases meeting or equalling the listing: Category for disability that will meet SSA's legal definition for disability. These are cases in which two or more conditions are running concurrently, and the combined effects of these conditions qualify the applicant for disability benefits.
catchment area (a CHAMPUS term): A region which is defined by postal zip code boundaries that fit roughly within a 40-mile radius of the government medical treatment facility and is used to determine the need for preauthorization for any civilian medical care.
*CHAMPUS: (Civilian Health and Medical Pro gram of the Uniformed Services) A comprehensive federal civilian medical care program for spouses and dependents of those in the uniformed services, either active duty personnel or those who died while on active duty, as well as retired personnel, their spouses, and dependents. (Also known as TRICARE.)
CHAMPUS Extra Plan: A combination of regular CHAMPUS and CHAMPUS Prime cover ages available in specific states. (Also known as TRICARE Extra.)
CHAMPUS Prime Plan: Full medical care plan administered by a CHAMPUS-designated HMO for CHAMPUS-eligible persons in specific areas of the country. (Also known as TRI CARE Prime.)
CHAMPUS sponsor: Uniformed services personnel who are either on active duty, retired, or have died while in the service.
CHAMPVA: A federal program for medical care in the civilian community for spouses and dependents of veterans with total service-connected disabilities or who died as a result of service-connected disabilities.
charge slip: Summary of services rendered to the patient during a visit. Includes the date, patient's name, and list of all services rendered on that particular date.
Civil Service Retirement System (CSRS): The older of two retirement programs for civil service employees of the federal government. All employees hired prior to 1984 were enrolled in this program.
claim: A demand for payment of covered medical expenses sent to an insurance company.
claim attachment: Additional claims documentation needed to adjudicate the claim.
clean claim: A filed claim that is properly filled out and contains all the data necessary for immediate processing by the insurance carrier.
closed fracture: A fracture that does not break the skin.
closed fracture treatment: Alignment of a fracture without surgical intervention.
closed-panel HMO: An established insurance program that allows members to receive non- emergency health services from contracted providers at specified facilities.
*COBRA insurance: The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 gave employees who leave a company with employer-sponsored group health insurance the right to continue their health insurance coverage for up to eighteen months, if they are willing to pay the entire cost of premiums. Medicare is primary to COBRA insurance.
*code modifier: A specific two-digit code added to CPT-4 main codes or a two-character code added to HCPCS Level 11 and III codes to indicate a deviation from the provider's normal fee. Use of a code modifier will keep the specific procedure out of the profile determination calculation.
coinsurance: See coinsurance payment.
coinsurance payment: A specified percentage of insurance determined for each service the patient must pay the health care provider.
combination programs (a Workers' Compensation term): A mix of different style Workers' Compensation programs from which employers can choose to insure employees against injuries/disorders acquired within the scope of their employment.
combined medical/surgical case: An in- patient hospitalization where the patient was first admitted as a medical case but, after testing, required surgery.
common data file: An abstract of all recent insurance claims filed for a patient.
comprehensive history and physical examination: A CPT Evaluation and Management Service requiring a documented patient history that includes the chief com plaint; an extended discussion of the history of the present illness; a complete review of the patient's past, family, and social histories; a comprehensive review of all body systems; and an extensive physical examination of either all body systems or a single organ system.
comprehensive NFS assessment: A nursing care plan for patients in skilled nursing facilities that includes the patient's functional capacity and identification of potential problems and nursing plan to enhance or maintain the patient's physical and psychosocial functions.
concurrent condition: Disorders present at the same time as the primary diagnosis that complicates the treatment required or lengthens the expected recovery time of the primary condition.
"conditional primary payor status": A Medicare phrase indicating that Medicare will pay an assigned claim as a primary payor under the following circumstances: 1) the normally designated primary payor denied payment; 2) the patient who is physically or mentally impaired failed to file a claim with the regular primary carrier; 3) A claim has been filed with the a liability carrier, but 120 or more days have passed without a response from the carrier.
confirmatory consultation: An examination of a patient for the purpose of giving an opinion about the necessity or appropriate nature of the patient's treatment plan. Most insurance carriers require these second opinion consultations prior to the authorization of nonemergency hospital admission.
*consultation: An examination of a patient by a health care provider to assist the referring/ attending physician in the evaluation and/or management of a specific case. Consultants may initiate diagnostic and/or therapeutic services as necessary.
contract: An agreement between two or more parties to perform specific services or duties.
*conventions: Special terms, punctuation marks, abbreviations, or symbols used as shorthand in a coding system to efficiently communicate special instructions to the coder. If the conventions are ignored, the code number established may be incorrect.
Coordinated Home Health and Hospice Care Program: A BCBS managed care option that allows the patients to elect an alternative to the acute care setting. If elected, the patient's physician must file a treatment plan with the BCBS case manager, and all authorized services must be rendered by personnel from a licensed home health agency or approved hospice facility.
*coordination of benefits (COB): A clause written into an insurance policy or stipulated by state law that requires insurance companies to coordinate the reimbursement of benefits when a policyholder has two or more medical insurance policies. The benefits from the combined policies may pay up to, but may not exceed, 100 percent of the covered benefits of the combined policies for all medical expenses submitted.
copay: See copayment.
*copayment: A provision in an insurance policy requiring the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical services they receive. HMO contracts state the copayment should be made at the time the service is per formed. (Also known as copayment.)
Correct Coding Initiative: See National Correct Coding Initiative.
Cost-based HMO: A Medicare-HMO plan that allows the Medicare beneficiary to receive care through the HMO without loss of the traditional Medicare program. If the patient goes outside the HMO network for care, the claim is submitted to the traditional Medicare carrier for processing.
cost-share payment: OCHAMPUS terminology for copayment.
covered charge: The fee for a procedure or service that is reimbursable under terms of the patient's insurance policy.
covered lives: A managed care term describing the number of persons enrolled in the program.
*CPT-4: (Physician's Current Procedural Terminology, Fourth Edition) A medical procedure coding system maintained and published by the American Medical Association.
CPT Main Number: A five-digit medical procedure code in the Current Procedural Terminology coding system assigned to identify a specific medical service.
critical care services: Medical care for critically ill patients who require the constant attention of physicians; this care is usually, but not exclusively, administered in the emergency or critical care facilities of the hospital.
Current Procedural Terminology (CPT Code): The coding system published by the American Medical Association, used for coding outpatient procedures and services per formed by health care providers.
customary fees: Either the average fee charged for a specific procedure by all comparable doctors in the same geographical area; or the 90th percentile of all the fees charged for a specific procedure by comparable doctors in the same geographical area.
daily accounts receivable journal: See day sheet.
day sheet: Chronological summary of all the practice's financial transactions posted to individual patient ledgers/accounts on a specific day.
*deductible: A specified amount of annual out of-pocket expense for covered medical services that the insured must incur and pay each policy year to a health care provider before the insurance company will pay benefits.
Defense Enrollment Eligibility Reporting System (DEERS): The CHAMPUS computerized listing of all CHAMPUS/CHAMPVA eligible dependents. Verification of eligibility may be obtained by calling the HBA and asking for a DEERS check on a patient.
dependent: Person who, by virtue of the financial support provided by the policyholder, meets the legal requirements for inclusion in a policy or program.
detailed history and physical examination: A CPT evaluation and management service requiring a documented patient history that includes the chief complaint; an extended discussion of the present illness; a review of the involved body systems plus limited number of other systems; the pertinent past, family, and/or social histories that are related to the patient's problem; and an extended examination of the involved body system and related organs.
diagnostic code: The statistical code number assigned by the World Health Organization for a specific diagnosis. This number appears in the International Classification of Disease-9th Edition-Clinical Modification (also called ICD, ICD-9, or ICD-9-CM code), which is distributed by the U.S. Government Printing House.
diagnostic reference numbers: The Item Numbers I through 4 that are preprinted in Block 21 of the HCFA 1500 claim form.
*Diagnostic Related Payment Groups: This is a method of reimbursement by episode of care that is applied to inpatient billing. See episode of care reimbursement.
direct-contact model IPA: An HMO that con tracts directly with the individual physicians rather than with an intermediary or association of physicians.
direct insurance payments: Payments sent directly from the insurance company to the physician's office for claims submitted on behalf of a policyholder.
disability compensation programs: Pro grams that reimburse insured workers for loss of income while they are unable to work due to an injury or illness.
*disability insurance: Reimbursement for lost income resulting from a temporary or permanent illness or injury.
Disease Index: The alphabetical listing of diseases and disorders in ICD-9-CM.
Disease Tabular List: The numerical listing of diseases found in ICD-9-CM. Also known as Volume I or Tabular List.
domiciliary care: Medical services provided to patients who reside in custodial care facilities that do not have 24-hour nursing care.
Drug Formulary: A published list of approved drugs.
*durable medical equipment (DME): Non disposable medical devices.
durable medical equipment carrier (DMERC: The regional fiscal agent that processes Medicare claims for durable medical equipment.
E codes: ICD-9 codes for the external causes of injury, poisoning, or other adverse reactions that explain how the injury occurred.
*E & M codes (Evaluation and Management codes): CPT codes that describe patient encounters with health care professionals for the purpose of evaluation and management of general health status.
Early and Periodic Screening Diagnostic and Treatment Services (EPSDT): A Medicaid program to uncover and treat chronic physical and/or mental disorders in beneficiaries under the age of 21.
electronic mail: The transfer of information from one computer to another via an electronic link.
electronic mail claim (EMC): A claim that is transferred electronically from health care providers' offices to insurance carriers.
Emergency Department Services: Medical services provided in an organized hospital based emergency room facility that is open 24 hours a day for the provision of unscheduled, episodic services to patients requiring immediate medical attention.
Employer Group Health Plan : Company sponsored group health plan covering 50 or more employees that is primary to Medicare.
Employer Self-insured Programs: Programs whereby employers with sufficient capital insure their own employees against loss of medical expenses and/or wages without contracting with a commercial carrier for coverage.
Employer-sponsored Retirement Plan: A health insurance conversion plan offered to employees of certain companies at the time of their retirement. These plans are intended to complement the retiree's Medicare cover age, and are not regulated by the federal government.
*Employer Tax Identification Number (EIN): The federal tax number assigned to all employers for the purpose of reporting and depositing of federal tax and Social Security money withheld from the employee salaries. The EIN is also used as the billing entity identifier in Block 25 on the HCFA 1500 claims form.
encounter form: This is the financial record source document used by health care providers and other personnel to record the patient's treated diagnoses and services rendered to the patient. Also known as the charge slip, routing form or superbill.
end-stage renal disease (ESRD): A chronic kidney disorder that requires long-term hemo dialysis or kidney transplantation because the patient's filtration system in the kidneys has been destroyed. Workers who have paid into the Social Security/ Medicare Fund and their dependents with ESRD who meet specific ESRD requirements are covered by Medicare.
entitlement program: A government pro gram in which the recipients receive some form of financial assistance via a special formula that determines eligibility.
episode of care reimbursement: A payment method in which the health care provider receives one lump sum for all services rendered to the patient for a specific illness or injury.
*established patient (as used in CPT coding): A patient who has an established chart and has received health care services within the last 3 years from the original physician or another physician of the same health care specialty in the same group practice.
Evaluation and Management Services: A CPT classification of services covering patient encounters with physicians for the purpose of evaluating and managing the patient's health status.
exclusions (exceptions): Disorders, diseases, Or treatments listed as uncovered services (not reimbursable) in an insurance policy.
exclusive provider organization (EPO): A closed-panel PPO plan where enrollees receive no benefits if they opt to receive care from a provider who is not in the EPO.
expanded problem focused history and physical examination: A CPT evaluation and management service requiring a documented patient history that includes the chief complaint, a brief discussion of the present illness and review of the pertinent body system, and a physical examination limited to the affected body systems and related organ system(s).
*explanation of benefits (EOB) form: An insurance report accompanying all claim payments which explains how the insurance company adjudicated a claim.
extra coverage plan : Specialized insurance plans which cover specific diagnoses or which fall into the special hospital indemnity class.
Federal Employee Program (FEP): The BC/ BS Federal Employee Plan. One of the many nationwide health benefit plans available to employees of the federal government. See Federal Employee Health Benefit Program.
Federal Employee Health Benefit Program (FEHBP): A program administered by the federal office of Personnel Management to provide medical insurance for federal employees as authorized under the Federal Employee Health Benefits Law.
Federal Employee Retirement System (FERS): The newer of two retirement programs for civil service employees of the federal government. All employees hired since 1984 are covered under this program.
Federal Insurance Contribution Act (FICA): A federally mandated payroll deduction, better known as the Social Security pay roll tax.
*fee-for-service (a medical office bookkeeping and insurance term): A method whereby the physician or other health care provider bills for each visit or service rendered rather than on an all-inclusive or prepaid fee basis.
fee-for-service plan: A contract where the carrier allows the patient complete freedom of the choice of health care providers. The reimbursement is made either according to a set fee or agreed upon percentage of the charge for each covered health care service rendered to a plan enrollee.
fee-for-service reimbursement: The long standing traditional form of reimbursement in which the individual service performed is itemized, priced, and charged to the patient's account. Payment is made by the patient or a third-party payer.
fee-for-service with utilization: A form of the traditional fee-for-service reimbursement method that adds some form of prospective and/or retrospective review of the provider's treatment and discharge planning to the individual itemization and pricing of each service.
*fee schedule: The listing in an insurance policy stating the maximum dollar amount the insurance company will allow for specific medical procedures performed on a patient. (Also called a schedule of benefits.)
first party: The person designated in a contract to receive the contracted service.
First Report of Injury Form: A form filed by the health care provider when a patient initially seeks treatment for a work-related injury or disorder.
fiscal agent: See fiscal intermediary.
fiscal intermediary: An insurance company selected by competitive bidding to process claims payments for a government insurance program.
fiscal year: Any 12-month period used by government or a business entity for its annual financial accounting cycle.
for-profit corporation: Enterprises that pay taxes on profits generated by the corporate's for-profit enterprises and pay dividends to shareholders on the after-tax profits.
for-profit insurance program: Policy established by a profit-making general insurance company.
fragmented surgery: The breaking down of an integrated major surgical package into its various components for the purpose of differential coding and obtaining higher reimbursement. (Also called unbundling.)
*fraud: Deliberate misrepresentation of facts.
full disability: Classification of disability where the patient has lost full capacity to earn a living.
*gatekeeper: Primary physician or other health care professional assigned by the insurer to review the medical management of plan enrollees.
*global fee: The fee for total care of a surgical case including all pre/postoperative care. This applies to surgical cases listed in the CPT code book which do not have an asterisk (*) at the end of the code number.
global surgery: A Medicare billing term that requires an all-inclusive fee for the following services: preoperative services performed by the surgeon within 24 hours of surgery, all interoperative procedures, treatment of surgical complications not requiring a return to the operating room, and 90 days of surgery related postoperative care.
group model HMO: An HMO that contracts with an already existing multispecialty group practice to perform all services for the HMO. In some cases the providers contract to work exclusively for the HMO and treat patients within the plan's facilities. In other cases, they are free to accept private, non-HMO patients and see both categories of patients in their private offices.
group policy: An insurance policy purchased by an organization or association as a benefit to its employees or members. Typical groups are employers, union or trade organizations, and professional associations.
group practice: Three or more health care providers joined to provide health care who jointly use equipment, supplies, personnel, and divide income by a prearranged formula.
guardian: Person who has legal responsibility for a minor child or an incompetent adult.
hard copy: A printed copy of a computer file.
*HCFA 1500 form: The standard insurance form used to report outpatient services to insurance carriers.
HCFA Level I Codes: HCPCS designation for CPT-4 codes.
HCFA Level Il Codes: HCPCS designation for alphanumeric codes used to augment CPT-4 codes.
HCFA Level III Codes: HCPCS designation for codes assigned for use by regional Medicare fiscal agents to clarify nonreimbursement issues on claims. HCPCS: The HCFA Common Procedural Coding System used for reporting outpatient health care services provided to Medicare beneficiaries. This coding system is arranged in three levels: Level I contains the CPT-4 codes; Level 11 contains HCFA-developed alphanumeric codes for reporting physician andnonphysical services not included in CPT-4; Level III contains Medicare carrier codes covering Medicare reimbursement issues.
Health Benefits Advisor (HBA): An individual stationed at Uniformed Service facilities who has responsibility for advising and assisting CHAMPUS beneficiaries obtain health care within the military and/or civil Ian communities.
health care: The performance of diagnostic, therapeutic, and preventive services and procedures by health care providers to persons who are sick, injured, or concerned about their health status.
*Health Care Financing Administration (HCFA): A federal administrative agency charged with primary responsibility for Medicare and the federal portion of the Medicaid programs.
Health Care Finder (HCF): A referral program to encourage the use of civilian CHAMPUS participating providers by CHAMPUS patients.
*health care fraud: Knowingly and willfully executing, or attempting to execute, a plan to 1) defraud any health care benefit program; or 2) obtain, by false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, a health care benefit program.
health care specialist: A health care provider who is not a primary care physician.
health insurance: A contract between the policyholder and an insurance carrier or government program to reimburse the policyholder for all or a portion of the cost of medically necessary treatment or preventive care rendered by health care professionals.
*Health Insurance Portability and Account ability Act: Legislation passed by Congress in the summer of 1996 that contains provisions for insured persons enrolled in employer sponsored insurance programs to retain the right to new health insurance when they change jobs without regard to their current health status; a prohibition on the use of genetic testing information to deny health insurance coverage; and strengthens existing fraud, abuse and confidentiality issues. This law is also known as the Kennedy-Kasselbaum bill or the Kasselbaum-Kennedy bill.
health maintenance organization (HMO): A prepaid, managed care, health care provider group practice with responsibility for providing health care services for a fixed fee to sub scribers in a given geographical area.
home plan: A BC/BS term used in the BlueCard Program literature when discussing the patient's out-of-area plan.
hospice: Autonomous, centrally administered program of coordinated inpatient and outpatient services to serve terminally ill patients and their families.
hospital discharge day: Final examination of the hospitalized patient, discussion with patient and/or their caregiver about hospital stay and instructions for postdischarge continuing care, and preparation of patient's discharge records.
hospital observation service: A CPT outpatient E&M service, provided by the attending physician, for patients who are "admitted for observation."
host plan: A BC/BS term used in the BlueCard Program literature when discussing the provider's local plan. ICD-9: International Classification of Diseases, Ninth Edition, published by the World Health Organization. ICD-9-CM: An extension of the World Health Organization's ICD-9 coding system developed for use in the United States for reporting diseases and indexing hospital records to the U.S. Public Health Service and HCFA.
Indemnity medical insurance plan: A regular commercial fee-for-service insurance pro gram.
*Independent practice association: A group of individual health care providers who join together to provide prepaid health care to individuals or groups who purchase coverage. This is a closed-panel HMO that has no common facilities.
indirect insurance payments: Payments sent to the patient as reimbursement for medical expenses incurred and paid.
individual insurance plan: An insurance policy sold to individuals who are not eligible for medical insurance under a group policy or to persons who need more coverage than is available to them through their group plan.
individual policy: See individual insurance plan.
Individual Practice Association (IPA): See independent practice association.
initial hospital visit: The first hospital inpatient encounter the admitting physician has with the patient for each admission.
in-network provider: See participating provider.
*inpatient: A person who is admitted to the hospital for treatment with the expectation that the patient will remain in the hospital for a period of 24 hours or more. The inpatient admission status is stipulated by the admitting physician.
inpatient medical case: A patient who is admitted to the hospital for medical care and billed on a fee-for-service basis.
inpatient surgery case: A patient who is admitted to the hospital and has surgery.
insurance: Protection against risk, loss, or ruin by a contract in which an insurer or under writer guarantees in return for the payment of a premium to pay a sum of money to the insured in the event of some contingency such as death, accident, or illness.
insurance abuse: Incidents or misrepresentations that are inconsistent with acceptable practice of medicine which lead to improper reimbursement, treatment that is not medically necessary for a disorder, or procedures that are harmful and/or of poor quality.
insurance carrier: The insurance company (insurer) that sells the policies and administers the contract.
insurance fraud: See fraud.
insured: A policyholder; the subscriber; the person who contracts with an insurance company for insurance coverage.
insurer: See insurance carrier.
integrated delivery system: A health care organization of affiliated provider sites combined under a single ownership that offers the full spectrum of managed health care.
*International Classification of Diseases 9th Revision-Clinical Modification (ICD-9-M): The numerical coding system used by all health care providers in the United States to classify and report diagnoses, External causes of injury and other medically justifiable reasons for seeking health care.
Inter-Plan Teleprocessing Service (ITS): A Blue Cross/Blue Shield Association electronic system that enables quick computerized processing of claims for patients who have policies originating outside of the provider's local area and that have an insured's identification number with an ITS-assigned alpha prefix.
itemized pricing: See unbundling.
Joint Commission on the Accreditation of Healthcare Organizations JCAHO): An organization that accredits hospitals, nursing homes, and other health care facilities
KISS: Keep It Short and Simple
KISS letter: A medical report written in plain English rather than technical terms that describes an unusual procedure, special operation, or a patient's medical condition that warrants performing surgery in a site different from the HCFA-stipulated surgical site.
Large Group Health Plan: Employer-sponsored group health plan that covers 20 or more employees and is primary to Medicare.
late effect: An adverse residual effect (sequela) of a previous illness, injury, or surgery.
lesion: Any discontinuity of the skin or an organ.
Level I Codes: See HCFA Level One Codes.
Level 11 Codes: See HCFA Level Two Codes.
Level III Codes: See HCFA Level Three Codes.
liability: The probable cost of meeting an obligation.
liability insurance: Insurance which covers losses to a third-party caused by the insured; or by an object owned by the insured; or on the premises owned by the insured. Malpractice, auto, and homeowners insurance are all specific types of liability insurance.
life time reserve days (Medicare): An additional 60 days of inpatient hospitalization that may be elected by the patient when the normal 90 day hospitalization stay per spell of illness has been exhausted. Each patient is allotted 60 additional days per life time.
limited license practitioner: A health care professional who is licensed to perform specific medical services in an independent practice.
CHAMPUS: NonPAR providers are limited to charging up to 15 percent above the CHAMPUS PAR fee schedule, and may not balance bill. Claims from independent laboratory, diagnostic laboratory companies, durable medical equipment and medical supply companies are not held to the limiting charge rule.
Federal Employee Health Benefit Pro gram: Charges on claims submitted for retired federal employees who are not eligible for Medicare are limited to the Medicare Fee Schedule rules.
Medicare: NonPAR providers filing nonuse signed claims are limited to charging no more than 15 percent above the NonPAR Medicare Fee Schedule which is 5 percent below the PAR Fee Schedule. Balance bill in on unassigned claims is subject to state regulations.
Limiting fee: See limiting charge.
liquid assets: Cash and property a person possesses that can immediately be converted to
lock-in provision: A Medicare-HMO provision restricting payment for unauthorized nonemergency services provided by out-of-network providers to patients enrolled in risk-restricted plans.
Major Medical (MM) coverage: A policy designed to cover some or all of the following outpatient medical services: durable medical equipment, prescription drugs, dental care services, and private duty nursing.
major surgery: A CPT term referring to surgery procedures that do not have asterisks after the code number, and therefore are billed as a surgical package.
malignant: A tumor that is invasive (has spread to deeper tissue) and is capable of spreading to other, remote parts of the body.
*managed care organization (MCO): A health insurance organization that adheres to the principles of strong dependence on selective contracting with health care providers, the use of primary care physicians or case managers as gatekeepers, prospective and retrospective utilization management, use of treatment guidelines for high cost chronic disorders, and an emphasis on preventive care, education, and patient compliance with treatment plans.
managed health care: See managed care.
Mandatory Second Surgical Opinion: This is a managed care option that requires a second surgical opinion be obtained by the patient before they undergo elective, non emergency surgical care.
manual daily accounts receivable journal: See day sheet.
Material Safety Data Sheets (MSDS): All employers are required to obtain and retain the manufacturer's data sheets on all chemicals and hazardous substances used on site. They are also required by the OSHA Act of 1970 to give all employees training in the safe handling of these substances.
maximum benefits: The highest amount the insurance company will pay for medical claims during a specified period. This amount is set either on a yearly basis or for the lifetime of the policy.
M codes: Morphology of neoplasms (tissue type) codes in the ICD system used to gather statistical data on the occurrences of specific tumors in the general population. These codes should not appear on physicians' office insurance claims.
*Medicaid: Combined federal/state program designed to help people on welfare or medically indigent persons with medical expenses. (Also known as Medical Assistance Program.) MediCal: Title that the state of California gives to the Medicaid Program.
Medical Assistance: Medical coverage pro vided by Medicaid/MediCal programs.
medical care: Diagnostic and treatment measures provided by health care professionals to persons who are sick, injured, or concerned about their health status.
medical claims with no disability: Workers' Compensation classification for a minor injury/disorder where a worker is treated by a physician and is able to continue working or returns to work within a few days.
medical decision making: Making a judgment about the complexity of establishing the diagnoses and the selection of treatment options.
medical emergency care: Immediate treatment sought and received for sudden, severe, and unexpected conditions which, if not treated, would place the patient's health in permanent jeopardy or would lead to permanent impairment or dysfunction of an organ or body part.
medical emergency care rider: An insurance clause that covers immediate treatment sought and received for sudden, severe, and unexpected conditions which, if not treated, would place the patient's health in permanent jeopardy, or would lead to permanent impairment or dysfunction of an organ or body part.
medical insurance: Contract between the policyholder (insured) and an insurance company (insurer) for reimbursement of a portion of the policyholder's cost of medical treatment for conditions requiring medical services.
medically indigent: See medically needy.
medically necessary procedure: Procedure which is commonly accepted to be necessary for the proper treatment of the stated diagnosis.
*medically needy (a government insurance term): Special medical coverage to persons who are capable of covering their own basic living expenses but need Medicaid to cover their extremely high medical bills.
*Medicare: A federal health insurance program for people 65 years of age or over and retired on Social Security, Railroad Retirement, or federal government retirement programs, individuals who have been legally disabled for more than 2 years, and persons with end-stage renal disease.
Medicare Fee Schedule (MFS): Schedule of Medicare fees based on RBRVS factors. Non PARs are restricted to the limiting fees on this schedule.
Medicare/Medicaid Crossover Program (MCD): A combination of the Medicare and Medicaid/MediCal Programs that is available to Medicare-eligible persons with income below the federal poverty level.
*Medicare Part A: Benefits covering inpatient hospital and skilled nursing facility services, hospice care, home health care, and blood transfusions.
*Medicare Part B: Benefits covering outpatient hospital and health care provider services.
Medicare Secondary-Payor Plan (MSP): An insurance plan that is primary to Medicare.
Medicare Supplemental Plan: An insurance plan that covers the Medicare patient's deductible and copayment obligations. These policies may be purchased individually (Medi gap policies) or premiums may be paid through an employer-sponsored program for retirees of the company.
Medigap policy: An individual plan covering the patient's Medicare deductible and copayment obligations that fulfills the federal government standards for Medicare supplemental insurance.
Medi/Medi claim: A combined Medicare and Medicaid claim.
member hospital: Hospital that has signed a contract with a medical plan to provide special rates.
military treatment facility (MTF): A clinic and/or hospital located on a United States military base or institution. minor surgery case: See minor surgical procedure.
minor surgical procedure: Defined in the CPT as a relatively small surgical service too variable to be billed as an all-inclusive surgical package and identified with an asterisk following the code number.
mixed model IPA: An IPA that allows each enrollee to elect several options ranging from use of only plan providers to having all health care services outside of the IPA net work of providers.
modifier: See code modifier.
multiple surgical procedures: Two or more surgeries performed on a patient during the same operative session.
National Center for Health Statistics (NCHS): The organization that gathers information on diseases and injuries and deter mines the future changes in federally sponsored insurance programs.
National Committee on Quality Assurance (NCQA): A nonprofit organization that evaluates and accredits HMOs according to a set of standards designed to measure the HMOs ability to deliver good health care.
National Correct Coding Initiative: A pro gram developed by HCFA to correct procedural coding billing errors on government claims.
National Provider Identification Number (NPI): A HCFA-assigned health care provider number that is eventually intended to be used on all claims forms to aid in the detection and tracking of fraudulent and abusive claims submissions.
nationwide account: An insurance contract for employers that have workers based in more than one region of the country, where the benefits are the same throughout the country.
negotiated fee-for-service: A contracted approved fee rate for services rendered to IPA or HMO patients that is lower than specialists normally charge for services rendered to patients enrolled in traditional indemnity insurance plans or self-pay patients.
newborn care: The initial and subsequent examination of neonates in a hospital or other birthing facility setting.
new patient (as used in CPT coding): A per son who has not received any professional service from the health care provider or another provider of the same specialty in the same group practice within the last 36 months.
New Patient Intake Interview: An interview between the office staff and a prospective patient to gather preliminary data to ensure that the patient has called the appropriate health care office for an appointment and check on the patient's insurance eligibility and benefit status before giving the patient an initial appointment.
no charge procedure: A procedure performed for which no fee was charged.
nonavailability statement (CHAMPUS DD Form 1251): Preauthorization for nonemergency civilian health care issued by the base commander when medical care required for a CHAMPUS-eligible person is not available at a government medical treatment facility within the patient's catchment area.
noncovered procedure: See uncovered procedure.
nonparticipating limited fee: A stipulation in the Medicare and CHAMPUS/TRICARE laws that forbids the nonparticipating health care provider to charge a patient more than fifteen percent above the programs approved fee.
nonparticipating physician: A physician that has not agreed to accept the carrier-deter mined, allowed rate as payment in full for covered services performed and, therefore, expects to be paid the full amount of the fees charged for services performed.
*nonparticipating provider (NonPAR): A health care provider that has not signed a participating provider contract with an insurance carrier and has the right to bill the patient for the difference between the amount charged for a service and the insurance company's determined allowed fee. (Also known as a out of-network provider.)
nonprofit corporation: See not-for-profit corporation.
not-for-profit program: A charitable, educational, civic, or humanitarian program run by a profit or non-profit company where all profits generated by the program are returned to the operating fund of that program instead of being distributed to shareholders and officers of the company, thereby exempting the company from paying taxes on that program's net income. (Also known as a nonprofit program.)
nursing facility services (NFS): Services per formed in skilled-care, intermediate-care, or long-term care facilities, as well as nonpsycho therapeutic visits to patients in a residential psychiatric treatment facility.
observation discharge: A CPT E&M service used when a patient is discharged to home or another institution from observation status in the hospital.
OCHAMPUS: (Office of Civilian Health And Medical Program of the Uniformed Services) The federal Department of Defense agency located in Aurora, Colorado with administrative responsibility for the CHAMPUS program. (Also known as the TRICARE Support Office.)
*Occupational Safety and Health Administration (OSHA) Act of 1970. Legislation designed to protect all employees against injuries from occupational hazards in the work place. It has special significance for health care workers because any worker who might come into contact with human blood and infectious materials must be given specific training in the handling of infectious materials and the strict use of universal precautions to avoid contamination. Each person who might have exposure to infectious material must be given hepatitis B vaccinations. The law also stipulates that comprehensive records must be kept for 20 years of all vaccinations given and any accidental exposure incidents such as needle sticks. See Material Safety Data Sheets.
on-the-job injury: Injury sustained by an employee while working within the scope of his or her job description or while performing a service required by the employer. The worker does not have to be on company property at the time of the injury to qualify for Workers' Compensation.
open fracture: A fracture that causes a break in the skin.
open fracture treatment: A surgical procedure required to properly reduce the fracture.
open-panel HMO: An HMO plan that does not require preauthorization by the HMO primary physician if the patient self-refers to a specialist who is not a member of the HMO. The patient pays a large deductible and copayment before the HMO will reimburse the patient for care received from the non-HMO specialist.
open treatment of closed fracture: An incision is made over the fracture and some type of fixation device is applied.
OSHA Act of 1970: See Occupational Safety and Health Administration.
Out-of-Area Program: See BlueCard Program.
out-of-network provider: See nonparticipating provider.
outpatient: A person who falls into one of the following classifications depending on where the encounter took place: 1) health care provider's office, 2) hospital clinic, emergency room or same day surgery unit, 3) admitted to a hospital for observation.
outpatient care: Medical services provided to a patient in a hospital as an outpatient, in a physician's office, or in the office of other providers of patient health care services (e.g., physical therapist or psychologist).
Outpatient Pretreatment Authorization (OPAP): A BC/BS managed care program requiring preauthorization of outpatient physical, occupational and speech therapy service that requires the filing of periodic treatment forms.
outpatient surgery case: A person who has surgery at the hospital and is discharged from the recovery room on the same day.
partial disability: Disability cases where the patient has permanently lost a specific percentage of his or her earning capacity.
participating physician: A physician who has entered into a contract with the government or an insurance company to provide medical services to enrolled subscribers. In the contract, it is agreed that the physician will accept the insurance company's approved fee for each medical service and will bill the sub scriber for only the deductible subscriber copayments, and any uncovered services as stated in the subscriber's policy. (Also known as an in-network provider.)
*participating provider (PAR): A health care provider who has entered into a contract with the government or an insurance company to provide medical services to enrolled subscribers. In the contract, it is agreed that the health care provider will accept the insurance company's approved fee for each medical service and will bill the subscriber for only the deductible subscriber copayments, and any uncovered services as stated in the subscriber's policy. (Also known as an in-network provider.)
patient account record: A permanent record of all the financial transactions between the patient and the practice. All charges, personal payments, and third-party payments are posted to the patient's individual account record.
patient-health care provider contract: A contract between the patient or their guardian and the health care provider for performance of medical services in exchange for the patient's/guardian's agreement to promptly pay that physician's usual fee for the services performed.
patient ledger: See patient account record.
Payer Identification Number (PAYERID): A HCFA assigned identification number for all entities paying health insurance claims.
payer identifier: See payer identification number.
PAVERID (Payer Identifier): Individual national identification numbers to be issued by HCFA in late 1997 to be used by individual health care providers, group practices, and all third-party payers on all government claims.
*payor of last resort: An insurance carrier that is billed only if the patient has no other medical benefits, or if the patient's other insurers deny responsibility for some or all payment or have lower payment schedules for benefits covered by the payor of last resort.
per capita payments: See capitation.
*permanent disability: A legal term referring to an injured employee's diminished capacity to return to the work force. The employee is not expected to be able to return to the job held before the illness or injury or to have any other form of employment.
*physician component: The nontechnical portion of a diagnostic test, the physician's responsibility for the supervision and interpretation of test results and writing the report of the diagnostic finding. CPT rules require the use of modifier -26 when an institution covers the technical services involved in the diagnostic services and a noninstitutional based physician performs and bills for the physician component of the service.
Physician Current Procedural terminology (CPT): The official title of the procedural coding system developed and maintained by the AMA for use in reporting health care services performed in the outpatient setting. It is also known as Level I HCPCS codes.
physician extender Nonphysician employees of a medical practice who are licensed by the state to perform specific medical procedures under the direct supervision of a physician.
Physician-Hospital Organization (PHO): A business entity in which the hospital and selected physicians form a health care net work for the purpose of contracting with man aged care organizations to render health care for subscribers.
physician standby service: A CPT E&M service used to report the time a physician was immediately available to perform a specialized service for another physician. To qualify for this service the standby physician may not be pro viding care to another patient during the specified time, or the physician performed a service that is part of a global surgical procedure.
Point-of-Service Plan (POS): A plan that is either an open-panel HMO or PPO that allows the enrollees to choose between using the in network or out-of-network providers when ever they need medical care. The plan benefits are higher and the patients' out-of-pocket payments are lower if they use a network provider.
poisoning (Medicare Definition): An adverse medical state caused by an overdose of medication, the prescription and use of a medicinal substance prescribed in error, or a drug mistakenly ingested or applied.
policyholder: See insured.
PMPM payment: A designation in discussions on capitation contract or literature that informs the reader that the per capita payment method is based on a "per member per month" formula.
PPN provider: A health care provider who has signed a participating provider network agreement with a medical insurance company or managed care program.
PPO provider: A health care provider who has signed a participating provider agreement with a medical insurance company or man aged care program.
*pre-existing conditions: Medical conditions under active treatment at the time the application is made for an insurance policy.
Preferred Provider Network Agreement (PPN): A contract between an insurance company and a health care provider in which the provider has contractually agreed to notify the insurer when PPN patients are referred to non PPN providers.
Preferred Provider Network Plan (BCBS): A provider-driven managed care plan where the provider, not the patient, is responsible for adhering to the managed care provisions of the plan. The BCBS Provider Referral Unit must be notified when out-of-network referrals are necessary.
Preferred Provider Organization (PPO): Prepaid managed care, open panel, non-HMO affiliated plan that provides more patient management than is available under regular fee-for-service medical insurance plans and contracts to provide medical care for PPO patients for a special reduced rate.
Preferred Provider Plan (BCBS): A sub scriber-driven managed care plan in which the subscriber is responsible for staying in-net work, and adhering to managed care requirement if they want to avoid additional out-of pocket expenses for services received from out-of-network providers or for not obtaining the policy-required second surgical opinion, hospital admission reviews, or other managed care stipulations.
premium: The periodic payment made by the policyholder to an insurance company to initiate or to keep existing insurance coverage.
prepaid medical care: Contracts to individuals or groups for coverage of specified medical expenses.
prepaid medical plan: See prepaid medical care.
presumptive legally disabled: One of three categories for disabilities that will meet SSA's legal definition for disability. These are cases specifically designated in the SSA disability manual.
preventive medicine encounter: Coding category used when the patient sees the physician for a routine examination (such as an annual physical or for well-baby care), or when risk management counseling is pro vided to patients who are exhibiting no signs or symptoms of a disorder.
preventive services: Services rendered to a patient that are designed to help the individual avoid health and injury problems.
primary care manager (PCM): The CHAM PUS title for the managed care gatekeeper or primary care physician. '
*Primary care physician (PCP): A family practice, internal medicine, pediatric, and, in some plans, gynecology specialist responsible for providing all routine primary health care for the patient.
Primary Care Referral Form: A form pre pared by the primary care physician referring the patient to a specialist a
nd authorizing specific services.
*primary diagnosis: The condition considered to be the major health problem for the patient for the submitted claim. This condition is always listed and coded first on the insurance claim form.
primary malignancy: The original tumor site where the new growth began.
*principal diagnosis: The diagnosis determined after study to be the major cause of the patient's admission to the hospital. The principal diagnosis may or may not be the same as the primary diagnosis.
*principal procedure: A procedure performed for definitive treatment and most closely related to the principal diagnosis.
*prior authorization: Consent obtained by a health care provider from an insurance company to proceed with described treatment. Some companies will not pay benefits for specific procedures without prior approval.
private, commercial Workers' Compensation programs: Employer-purchased policy that meets state-determined requirements for Workers' Compensation coverage.
problem focused history and physical examination: A CPT evaluation and management service requiring a documented patient history that includes the chief complaint, a brief discussion of the present problem, and physical examination limited to an examination of the affected body or organ system.
procedural code: A statistical code system designed to communicate procedural data to insurance companies or other third-party payers.
Current Procedural Terminology (CPT Code): The coding system published by the American Medical Association.
*Health Care Procedural Coding System (HCPCS Code): An alphanumeric coding system devised by the federal Health Care Financing Administration (HCFA) as a supplement to the CPT code and distributed by the regional fiscal agents for Medicare, CHAMPUS, and Medicaid.
*Relative Value System (RVS) Code: (Sometimes referred to as California Standard Nomenclature System.) A coding system that originated with the California Medical Society. Now used by many State Workers' Compensation carriers.
Procedural Tabular List and Alphabetical Index: See Volume III (ICD-9-CM).
*professional component (CPT term): The portion of a diagnostic health care service that represents providers' responsibility for the supervision of technical staff, the interpretation of results, and the writing of the diagnostic report results.
profit corporation: An association of share holders bound together as one legal entity for the purpose of providing a service which will generate income for the officers and share holders.
progress report: Detailed narrative filed to report any significant change in the worker's medical or disability status.
prolonged care services: A CPT evaluation and management service used to describe unusual services beyond the normal E&M encounter service that is provided in either the inpatient or outpatient setting.
provider: A physician or other supplier of medical services or equipment.
Provider Identification Number (PIN): A computer number assigned to a health care provider by an insurance company to be used on all claims filed by that provider.
qualified diagnoses: Diagnoses stated in the records that are not yet proven and include words like "suspected," "possible," "question able," "suspicious of," or "ruled out."
Qualified Medicare Beneficiary Program (QMB): A program designed to pay Medicare premiums, deductibles, and patient copayments for all Medicare-eligible persons of all ages who have income at or below the federally set poverty level. R & C
Policy: See UCR Policy.
reasonable fee: As defined by the insurance industry, the allowed fee which was deter mined to be the lowest fee for a specific procedure appearing on either the usual or customary profile.
Referral: Total transfer of a patient's medical care to another physician for treatment limited to a specific disorder.
referring physician: The physician who sends the patient to another physician or other provider of health care services for consultation or treatment.
*release of medical information statement: A separate form or statement signed by the patient which authorizes release of treatment and diagnostic information by the provider to a third party.
residual functional capacity (RIC cases): Category for disability. In these cases the patient cannot work at their present job or do any other type of work related to their prior employment or occupation.
Resource-based Relative Value Scale (RBRVS): A medical insurance payment sys tem developed by a team of researchers at Harvard School of Public Health and headed by Dr. William Hsiao. The RBRVS formula has three separate cost factors: the physician's work factor, the provider's practice expenses less malpractice expenses, and cost of mal practice insurance. Each of the three cost factors are modified by a geographic index and then multiplied by a conversion factor that is determined annually by the U.S. Congress and converts the relative value units into a fee schedule.
respite care (insurance definition): The temporary hospitalization of a hospice patient for the purpose of giving relief from duty for the nonpaid person who has the major day-to day responsibility for the care of a chronically ill, dependent patient.
rider: An amending clause added to the original policy which may increase or decrease policy coverage.
Risk-Restricted HMO: This is a capitated Medicare-HMO plan that serves Medicare-eligible persons in a specific geographic area in lieu of their regular Medicare coverage. The patient is subjected to all the regular HMO constraints and procedures. Some plans have a lock-in provision that means neither the HMO nor Medicare will pay for unauthorized non-emergency care provided by out-of-network health care providers.
routing form: See encounter form.
schedule of benefits: See fee schedule.
second party: The person or organization in a contract that is designated to provide the service.
second primary insurance policy: When the patient is covered by two full benefit policies, the second primary insurance policy is the one that has the patient designated as a dependent, not as the policyholder. The patient is the policyholder on the primary policy.
secondary condition: A disorder running concurrently with the primary diagnosis that does not overtly affect the prognosis of the primary condition.
secondary malignancy: A tumor that has metastasized; cells have broken away from the primary site and a tumor mass is now found in a new location.
*secondary plan: A plan or policy that is second in responsibility for payment of benefits when a person is covered by two or more full benefit insurance plans.
self-insured plans: Special bank accounts established by businesses, state and county governments, and large labor unions for the sole purpose of paying the covered medical expenses of employees and their dependents.
self-referral: A patient who sees an out-of-net work provider with a referral from the primary care physician or case manager.
separate procedure: CPT term describing a surgical procedure that was performed as a completely independent procedure not related to any other procedure performed in the same operative session.
skin lesion: Any discontinuity of the skin.
SOAP charting format: A medical charting system.
S means subjective impression.
0 means objective clinical data.
A means assessment of the problem and diagnosis.
Pmeans plan for treatment, further studies and case management.
Social Security Administration (SSA) benefits: The support a person receives when they meet specific requirements and have paid into the retirement, old age, survivors, disability, and hospital insurance programs run by the federal government.
Social Security Disability Insurance (SSDI) Program: A federally administered entitlement program authorized by Title 2 of the Social Security Act.
*Social Security Number (SSN): A federal identification number assigned by the Social Security Administration for the purpose of tracking an individual's eligibility for designated governmental services, individual pay roll tax withholding accounts, etc. Insurance companies, banks, schools, and business corporations also use the SSN to identify individual clients.
*source document: The hard copy document (routing slip, charge slip, encounter form, Superbill, etc.) from which a claim is generated.
special accidental injury rider: A clause added to an insurance policy that covers 100 percent of nonsurgical care sought and rendered within 24 to 72 hours of an accidental injury.
Specified Low-Income Medicare Beneficiary Program (SLMB): A program designed to pay Medicare Part B premium for persons whose income falls in the federally designated "near poor" program.
"spell of illness": See benefit period.
sponsor (a CHAMPUS/CHAMPVA term): The name of the spouse or parent who is a member of the Armed Forces or the uniformed branch of the Public Health Service, the National Oceanic and Atmospheric Administration (NOAA), or the North Atlantic Treaty Organization (NATO).
Spousal Impoverishment Protection Legislation: Federal legislation that curbs the need for married couples to "spend down" income and other liquid assets (cash and property immediately convertible to cash) before one of the partners can be declared eligible for Medicaid coverage for nursing home care. The spouse remaining at home may have a minimum 1997 monthly income of $1,295, unless a fair hearing or court order establishes a higher figure for a specific individual. 1997 minimums for other resources are set at the greater of 1) a level between $15,896 and $79,020 established by the state where the individual resides, 2) 50 percent of the couple's affected resources that do not exceed one half of the $79,020 maximum, 3) the higher limit established in a fair hearing or by court order. The noninstitutional spouse may retain any income that is solely in his/her name.
SSA benefits: Social Security benefits.
SSA (Social Security) deduction: Federal payroll taxes to cover individual contributions to the old-age, survivors', disability, and Medicare funds under the Social Security Act. (Also known as the FICA withholding or tax.)
SSDI funds: Social Security Disability benefits.
staff model HMO: A closed-panel multispecialty group practice where all physicians are employees and all health care services, including ancillary services such as physical therapy, pharmacy, and central supplies, are provided within a corporate building.
State Compensation Board/Commission: An administrative agency set up by the state legislature to oversee the Workers' Compensation program within the state.
State Compensation Fund: A state government agency functioning as the insuring body to cover Workers' Compensation claims.
subrogation: The assumption of an obligation for which another party is primarily liable.
*subscriber: The insured; the insurance policy holder.
subsequent hospital visit: Inpatient encounter for the purpose of conferring with the patient to update the patient's progress, reviewing the patient's medical chart, writing new orders for diagnostic tests and treatment orders, and consulting with other health care professionals about the case.
Subsequent NFS visit: An encounter with an NFS patient for the purpose of assessing the patient's current status when no major, permanent change of status is present.
Sunshine Law: This law is officially known as the Privacy Act of 1979. One of its provisions forbids the regional government program carriers from disclosing the status of any unassigned claim to NonPAR providers.
superbill: See encounter form.
supplemental insurance: An insurance policy designed to cover the policyholder's deductible and copayment obligations of a full benefit primary insurance policy.
Supplemental Security Income Program (SSI): A federally administered income assistance welfare program authorized under Title 16 of the Social Security Act; this program provides cash payments to needy, aged, blind, or disabled persons.
*surgery or surgical procedure: (as used by the insurance industry)
A . Any treatment that breaks the normal skin barrier, such as injections, incisions, and excisions.
B. Examination with the aid of a scope that goes beyond the normal body orifice. A laryngeal mirror or vaginal speculum does not fit this definition because there is no penetration beyond the regular body orifice. Bronchoscopy, proctosigmoid examinations, and dilation of the cervix are examples that qualify for the surgery definition.
C. Treatment for burns.
D. Treatment for fractures, both open and closed.
E. Any procedure fitting the popular definition of surgery.
surgical package: (CPT definition) Surgical procedures where one fee covers the surgery, normal, uncomplicated follow-up care, and the injection of local anesthesia.
surgical procedure: (CPT definition) Those procedures that carry a CPT code number assigned from 10000 through 69999.
Tabular List: (as used in diagnostic coding) A numerical listing of diseases and their assigned code numbers.
*technical component (-TC): A HCPCS Level II modifier used to indicate the charge is for the technical portion of a diagnostic test (cost of running a machine, the supplies and the technical supervision portion) without the professional component.
*temporary disability: Workers' Compensation classification describing a situation where the worker is unable to perform his or her usual duties for a limited period of time. It is expected that the worker will fully recover from the disorder and be able to return to the job after a short-term disability leave.
*third party: Someone other than the persons directly involved in an action or contract; an outsider with no direct, binding, legal interest in a case.
third-party administrator: An administrator or corporation appointed by the insurer to oversee the authorization of medical treatments, performance of retrospective utilization, review of treatment plans, and payment of claims. This administrator has no direct interest in the health insurance contract.
third-party payment: A payment made by an insurance company, friend, attorney, and so on to a health care provider to pay for medical expenses incurred by a patient.
third-party payor: An individual or corporation that makes a payment on an obligation/ debt but is not a party to the contract that created the obligation/debt.
TRICARE Extra Plan: A PPO option available to CHAMPUS active duty dependents that requires no special enrollment and reduces the out-of-pocket expenses for medical care when services are obtained from a TRICARE network provider. (Also known as CHAMPUS Extra.)
TRICARE Prime Plan: An HMO option for enrolled active duty dependents that eliminates the need to file claim forms and greatly reduces the out-of-pocket expenses for medical care. (Also known as CHAMPUS Prime.)
TRICARE Standard Plan: Regular CHAMPUS benefits for service rendered by health care providers who are not enrolled in CHAMPUS PPO or HMO network. (Also known as Standard CHAMPUS.)
TRICARE Support Office: New name of OCHAMPUS. See OCHAMPUS. U & C Policy: See UCR Policy.
*UCR allowable charges: The amount the insurance company will pay for a given procedure calculated on the UCR (Usual, Customary, and Reasonable) basis; the lesser of either the provider's Usual Charge for the given procedure or the Customary Charge for the area. In the above statement Usual is defined as follows: the average fee for a given procedure the provider submits to the insurance company. Customary is defined as follows: the average or the 90th percentile of the charge (depending on how it is stated in the insurance policy) for a given procedure submitted to the insurance company by all the physicians in a designated geographical region. Reasonable means the same as "allowed" charges or approved fee.
UCR approved fee: See UCR allowable charges.
UCR charges: The insurance company's "approved fee" for a given medical procedure determined by calculating the charge submitted using the Usual, Customary, and Reason able formula. Also called the UCR Payment or UCR Profile.
UCR policy (Usual, Customary, and Regional/Reasonable Policy): A policy that uses the usual, customary, and reasonable average fee profiles to determine the "allow able" reimbursement for each procedure.
unauthorized services: Services provided to a managed care patient without proper authorization or a current authorization from the patient's primary care physician or case manager.
*unbundling: The breaking down of an integrated major surgical package into various components for the purpose of differential coding and obtaining higher reimbursement. (Also known as fragmented surgery.)
uncertain behavior: The designation for a tumor where the morphology or behavior of the tumor cannot be stated with certainty.
uncovered procedure: Any service determined not to be a benefit of the insurance policy, therefore disallowed for payment.
underwriter: The insurance company or governmental agency that sets all policy benefits and establishes all procedural rules for determination of the payment of benefits.
Uniformed Services: The Army, Navy, Coast Guard, Air Force, Marines, Public Health Service, and National Oceanic and Atmospheric Administration.
*Unique Provider Identification Number (UPIN): Assigned by HCFA and given to the physician for purposes of identification on forms and claims.
unspecified nature: A descriptive qualifier for a neoplasm when the histology or nature of the tumor has not been determined.
Utilization Review Organization: An organization responsible for authorization of treatments, payment of claims, and performance of retrospective utilization review for an insurance program. The organization has no direct interest in the insurance contract it administers or reviews.
V codes: ICD codes representing either factors that influence a person's health status or legitimate reasons for contacting the health facility when the patient has no definitive diagnosis or active symptoms of any disorder.
Veteran's Compensation Program: A program for needy veterans who become permanently and totally disabled due to a service related illness or injury, and who have a reduced earning capacity due to the illness or injury.
Veteran's Pension Program: A program for needy veterans who become permanently and totally disabled from a service-connected injury or illness and who will never be able to be gainfully employed.
vocational rehabilitation: Training in new job skills to enable a person receiving Workers' Compensation or disability funds to become gainfully employed in a new position.
Volume I (ICD-9-CM): The tabular (numerical) listing of diseases in the International Classification of Diseases coding system.
Volume Il (ICD-9-CM): The alphabetical index to Volume I (tabular listing of the international Classification of Diseases coding sys tem).
Volume III (ICD-9-CM): The tabular and alphabetical index of procedures in the International Classification
of Disease coding sys tem; used exclusively by hospital coders for inpatient procedure coding.
Welfare: Federal and state financial and other assistance given to persons whose income falls near or below the federally designated poverty level. Also known as public assistance.
*Workers' Compensation: An insurance pro gram mandated by federal/state governments that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders
*write-off (insurance definition): A reduction in the amount charged to the patient's account after the participating provider receives the insurance carrier's EOB. The write off is the difference between the fee the provider charged for medical services and the insurance carrier's allowed fee for those services.
ABBREVIATION OF HEALTH INSURANCE TERMS
A: Assessment and diagnosis data (See SOAP charting format)
AAPC: American Academy of Procedural Coders, Salt Lake City, UT
AFDC: Aid to Families with Dependent Children
AHA: American Hospital Association
AHIMA: American Health Information Management Association, Chicago, IL
AMA: American Medical Association
ASC: Ambulatory Surgical Center
APG: Ambulatory Payment Groups
BC: Blue Cross
BCBSA: Blue Cross Blue Shield Association
BC/BS: Blue Cross and/or Blue Shield
BCBS FEP: Blue Cross/Blue Shield Federal Employees Plan
BS: Blue Shield
E&M service listed on an encounter form
Care/Caid claim: A Medicare/Medicaid cross over claim
CCS-P: Certified Coding Specialist-Physician based
CHAMPUS: Civilian Health and Medical Pro gram for the Uniformed Services
CHAMPVA: Civilian Health and Medical Pro gram of the Veterans Administration
COB: Coordination of benefits
CPC Certified Procedural Coder
CPT. Current Procedural Terminology
CPT-4: Current Procedural Terminology, Fourth Edition
CSRS: Civilian Service Retirement System
D: Detailed E&M service listed on an encounter form
DEERS: Defense (CHAMPUS) Enrollment Eligibility Reporting System
DME: Durable medical equipment
DMERC: Durable medical equipment regional carrier
DRG: Diagnosis-Related Group
E&M code: Evaluation and management code
E/M: Evaluation and management
EGHP: Employer group health plan
ETIN: Employer Tax Identification Number
EMC: Electronic mail claim
EOB: Explanation of benefits
EPF: Extended problem focused level of E&M service listed on an encounter form
EPO: Exclusive Provider Organization
EPSDT. Early and Periodic Screening, Diagnostic and Treatment Services
ER: Emergency room
ESRD: End-stage renal disease
FECA: Federal Employee Compensation Act
FEP: Federal Employee Plan
FEHBP: Federal Employee Health Benefit Program
FERS: Federal Employee Retirement System
Fl: Fiscal intermediary
FICA: Federal Insurance Contribution Act; generally known as the Social Security deduction
Grp #: Carrier-assigned group practice number (See item 33 on the claim form)
HBA: (CHAMPUS) Health Benefits Advisor
HC: High complexity level of E&M service listed on an encounter form
HCF: (CHAMPUS) Health Care Finder Program
HCFA: Health Care Financing Administration
HCFA-1500 Insurance form designated by HCFA and many other insurance companies as the
preferred form for use when filing insurance claims
HCPCS: Health Care Procedural Coding System
HI SEV. High severity level of E&M service listed on an encounter form
HMO: Health maintenance organization
ICD: International Classification of Disease
ICD-9: International Classification of Disease Ninth Edition
ICD-9-CM: International Classification of Disease-Ninth Edition-Clinical Modification
IPA: Independent Practice Association
ITS: BCBS Interplan Teleprocessing Service
JCAHO: Joint Commission on Allied Health Organizations
KISS: Keep it short and simple
LC: Low complexity level of E&M service listed on an encounter form
LGHP: Large group health plan (employer-sponsored group plan)
LIM/MINOR: Limited or minor level of E&M service listed on an encounter form
LOW/MOD: Low to moderate level of E&M service listed on an encounter form
LOW SEV. Low severity level of E&M service listed on an encounter form
MC: Moderately complex level of E&M service listed on an encounter form
MCD: Medicare/Medicaid Crossover Program
Medi/Medi claim: Medicare/Medicaid cross over claim
MFS: Medicare Fee Schedule
MM: Major Medical benefits
MOD/HI: Moderate to high level of E&M service listed on an encounter form
MOD SEV: Moderate severity level of E&M service listed on an encounter form
MSDS: Material Safety Data Sheet
MSP: Medicare Secondary Payor plan
MTF: Military treatment facility
NCHS: National Center for Health Statistics
NCQA: National Committee for Quality Assurance
NF: Nursing facility
NFS: Nursing facility service
NPI: National Provider Identification Number
NonPAR: Nonparticipating provider
NPT: New patient
0: Objective clinical data; See SOAP charting format
OPAP: BCBS Outpatient Pretreatment Authorization Plan
OSHA: Occupational Safety and Health Administration
V. Office visit or outpatient visit
P: Plan of treatment; See SOAP charting format
PAR: Participating provider
PAYERID: Payer Identification Number
PCM: (CHAMPUS term) Primary Care Manager
PCP: Primary care physician
PF: Problem focused level of E&M service listed on an encounter form
PHO: Physician-Hospital Organization
PIN: Carrier-assigned Provider Identification Number
PMPM: per member per month
POS: Point-of-Service plan
PPN: Preferred Provider Network
PPO: Preferred provider organization
QMB: Qualified Medicare Beneficiary Program
RBRVS: Resource-based Relative Value Scale
RFC: Residual functional capacity
RVS: Relative Value Study
S: Subjective impression/or report of the patient (See SOAP charting format)
SLMB: Specified Low-Income Medicare Beneficiary Program
SOAP: Subjective, objective, assessment, and plan-a medical chart format
SP: Employer-sponsored Medicare supplemental programs
SSA: Social Security Account or Administration
SSDI: Social Security Disability Insurance Program
SSI: Supplemental Social Security Income
SSN: Social Security Number
SUPP: Supplemental Benefits
-TC: technical component modifier
U&C: usual and customary
UCR: Usual, Customary, and Reasonable; see UCR Allowable Charges
UPIN: Medicare's Unique Provider Identification Number
VA: Veterans Administration
XC: Extra coverage insurance plan covering specific disorders
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