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Glossary LUH
Certification
| Term | Definition |
|---|---|
| 1-Day Rule | a requirement that all diagnostic or outpatient services furnished in connection with the principle admitting diagnosis within one day prior to the hospital admission are bundled with the inpatient services for Medicare billing. |
| 3-Day Rule | a requirement that all diagnostic or outpatient services furnished in connection with the principle admitting diagnosis within three days prior to the hospital admission are bundled with the inpatient services for Medicare billing. |
| 5010A1 | the American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 1500), formerly the 837P |
| 837I | the American National Standards Institute transaction for an institutional claim; as a result of HIPAA, it is replacing the electronic UB-04 |
| 837P | a former American National Standards Institute transaction for a professional claim (the electronic equivalent of the CMS 1500), since replaced by the 5010A1 |
| ABN | the Advance Beneficiary Notice of Non-coverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity. |
| abuse | the misuse of a person, substance, service, or financial matter such that harm is caused; some forms of healthcare abuse include excessive or unwarranted use of technology, pharmaceuticals, and services; abuse includes improper billing practices |
| Accounts Receivable (AR) Days Outstanding | an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable. |
| ACF | Administration for Children and Families; one of the DHHS Operating Divisions. |
| ACL | Administration for Community Living; one of the DHHS Operating Divisions. |
| actual or expressed consent | written or oral agreement by the patient to the treatment outlined. |
| acute inpatient | a level of healthcare delivered to patients experiencing acute illness or trauma; it generally occurs in a hospital or emergency room and is generally short-term care rather than long-term or chronic care. |
| ADC | average daily census; the average number of inpatients maintained in the hospital each day for a specific period of time. |
| ADRR | Average Days of Revenue in Accounts Receivable; also known as Accounts Receivable (AR) Days Outstanding; in simple terms, this is an estimate of the time needed to collect the accounts receivable. |
| Advance Beneficiary Notice | the Advance Beneficiary Notice of Non-coverage; a form given to a Medicare beneficiary before services are furnished when a service does not meet or is not expected to meet medical necessity. |
| AFDC | Aid to Families with Dependent Children; a financial assistance program provided by DHHS. |
| Agents | individuals who help consumers/small businesses complete the application process and enroll in healthcare coverage through the Marketplacethey are able to make recommendations about coverage and may only sell plans from specific health insurance companies |
| AHA | the American Hospital Association |
| AHRQ | Agency for Healthcare Research and Quality; one of the DHHS Operating Divisions. |
| ancillary services | services other than routine room and board charges that are incidental to the hospital stay; operating room; anesthesia; blood admin; pharmacy; radiology; lab; medical, surgical, and central supplies; OT, PT, ST and other diagnostic services. |
| ANSI | the American National Standards Institute |
| APC | ambulatory payment classification; a payment methodology in which services paid under the prospective payment system are classified into groups that are similar clinically and in terms of the resources they require |
| assignment of benefits | a written authorization, signed by the policyholder to an insurance company, to pay benefits directly to the provider; when assignment is not accepted, the payment will be sent to the patient and the provider will have to collect it. |
| ATB | aged trial balance; a resource for internal collection efforts. |
| ATSDR | Agency for Toxic Substances and Disease Registry; on of the DHHS Operating Divisions. |
| average daily census | the average number of inpatients maintained in the hospital each day for a specific period of time |
| average daily revenue | the average amount of revenue or charges generated each day over a specified period of time. |
| Average Days of Revenue in Accounts Receivable | AR) Days Outstanding; an estimate, using average current revenues, of the days required to turn over the accounts receivable under normal operating conditions; in simple terms, this is an estimate of the time needed to collect the accounts receivable. |
| bad debt | an uncollectible account resulting from the extension of credit. |
| beneficiary | a person who has healthcare insurance through Medicare. |
| birthday rule | a rule to determine coordination for benefits for a child covered by both parents; it dictates that the parent with the first birthday in the calendar year will provide the primary coverage |
| Black Lung Benefits Act | legislation which provides for medical treatment for coal miners totally disabled from black lung disease. |
| Bressers | cross-reference directory used in skip tracing. |
| brokers | individuals who help consumers and small businesses complete the application process and enroll in healthcare coverage through the Marketplace; make recommendations about coverage and may only sell plans from specific health insurance companies. |
| CAH | Critical Access Hospital; a non-profit hospital has established a Medicare Rural Hosp. Flexibility Program; must have 25/or fewer beds/ALOS of 96 hours/or less, be located a minimum distance from other hospitals, and furnish 24-hour emergency services |
| Case management | also known as Utilization Review (UR); area performs critical tasks during registration and a patient's stay, such as reducing unnecessary admissions; managing the approved length of stay; ensuring an appropriate level of care for the patient's condition |
| CDC | Centers for Disease Control and Prevention; one of the DHHS Operating Divisions. |
| CDM | charge description master; the chargemaster or master pricing list that includes services, supplies, devices and medication charges for inpatient or outpatient services by a healthcare facility |
| CERT | Comprehensive Error Rate Testing |
| Certified application counselors | individuals (staff members or volunteers) who fulfill some of the same roles as Navigators and non-Navigators; they are not responsible for outreach and education but they do provide free information to consumers about insurance programs |
| CHAMPUS | Civilian Health and Medical Programs of the Uniformed Services; the programs replaced by Tricare to cover healthcare for active duty and retired members of the uniformed services, their families, and survivors. |
| Chapter 7 | bankruptcy individuals and businesses that cannot pay their debts based on income/except for exempt property as defined by state laws, debtor's assets are auctioned to satisfy creditor claims 70% of all bankruptcy claims filed under Chapter 7. |
| Chapter 11 | a type of bankruptcy frequently referred to as a "reorganization"; it gives a distressed business a reprieve from creditor claims while it continues to function and works out a repayment plan. |
| Chapter 12 | a type of bankruptcy for a family farmer with "regular annual income." |
| Chapter 13 | bankruptcy individuals w/regular income who desire to pay their debts, but are unable to do so; the debtor, under court supervision protection, may propose and carry out a repayment plan under which creditors are paid over an extended period of time. |
| chargemaster | also known as charge description master (CDM); the master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services by a healthcare facility. |
| charity care | service provided that is never expected to result in cash flow. |
| CHIP | the Children's Health Insurance Program; program children whose parents have too much money to be eligible for Medicaid, but not enough to buy private insurance; it is jointly financed by the federal and state governments, and administered by the states. |
| CLIA | the Clinical Laboratory Improvement Amendment of 1988; legislation requiring all clinical laboratory services furnished to Medicare beneficiaries to be performed by a provider who has a CLIA certificate. |
| CMP | civil monetary penalty |
| CMS | Centers for Medicare and Medicaid Services; on of the DHHS Operating Divisions. |
| CMS 1450 | another name for the UB-04 uniform bill form. |
| CMS 1500 | the billing form used to submit physician and professional service claims to Medicare |
| CO | compliance officer. |
| COB | coordination of benefits; the determination of which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. |
| Common Working File | a CMS file that contains Medicare patient eligibility and utilization data. |
| conditional payment | a payment made when another payer is responsible, but the claim is not expected to be paid promptly (usually within 120 days from receipt of the claim); it prevents the beneficiary from having to pay out of pocket |
| Consumer assistance programs | a resource to help to address consumers' problems or questions about health coverage. |
| Consumer Credit Protection Act | first general federal consumer protection legislation; its provisions include the Truth in Lending Act, the Fair Credit Billing Act, the Fair Credit Reporting Act, and the Fair Debt Collection Practices Act. |
| coordination of benefits contractor | entity that assists with the collection, management, reporting of other health coverage; COB contractors do not process claims for the provider; they gather and disseminate COB info to ensure Medicare is not making primary payment for a service in error. |
| courtesy discharge | a type of discharge in which a patient's financial considerations have been met so he or she is allowed to leave the hospital without going through the usual formalities; the patient is billed at a later date |
| CPT | Current Procedural Terminology; a system of descriptive terms and five-digit numeric codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. |
| CPU | central processing unit |
| CRA | credit reporting agency. |
| Criminal Health Care Fraud Statute | statute that prohibits willfully or knowingly executing a scheme to obtain any money or property owned by or in control of any healthcare benefit program or defrauding any healthcare benefit program. |
| Critical Access Hospital (CAH) | a non-profit hospital located in a state that has established a Medicare Rural Hospital Flexibility Program; 25 or fewer beds,ALOS of 96 hours or less, be located a certain minimum distance from other hospitals, and furnish 24-hour emergency care services |
| custodial care | care that is primarily for the purpose of meeting personal needs; persons without professional training may provide custodial care; it is not covered by Medicare. |
| CWF | Common Working File; a CMS file that contains Medicare patient eligibility and utilization data. |
| data mailer | a system-generated, free-form statement that is used to communicate the status of a patient's account and/or to bill the patient for an unpaid amount remaining on the account. |
| definitive LCD/NCD | a policy that discusses and lists specific diagnosis codes, ICD procedure codes, and possibly signs and symptoms to support the need for the item or service being given. |
| DHHS | Department of Health and Human Services; the United States government's principal agency for protecting the health of all Americans and providing essential human services; it is also the federal government's largest grant-making agency. |
| discharge of debtor | a potential outcome of bankruptcy that releases the guarantor/patient from financial responsibility of any and all account balances listed on the bankruptcy petition; the account balance is to be written off to the appropriate transaction code. |
| dismissal | a court ruling whereby a bankruptcy is rejected by the court; the most common reason for dismissal is the failure of the debtor to follow through on the filing process and on payment to the attorney |
| DME | durable medical equipment, such as wheelchairs, hospital beds, oxygen, and walkers. |
| DMEPOS | durable medical equipment, prosthetics, orthotics, and supplies. |
| DOJ | Department of Justice; one of the entities, along with the Office of Inspector General (OIG), that coordinates fraud and abuse control. |
| DSMT | Diabetes Self-Management Training. |
| dual eligible | an individual who is entitled to Medicare Part A and/or Part B, and also eligible for some form of Medicaid benefit. |
| Durable Power of Attorney for Healthcare | also known as Healthcare Power of Attorney; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so. |
| ECOA | Equal Credit Opportunity Act; a law that prohibits credit discrimination on the basis of race, color, religion, national origin, sex, marital status, age, or because someone receives public assistance. |
| E&M | evaluation and management; both the process of and the charge for examining a patient and formulating a treatment plan. |
| EGHP | Employer Group Health Plan. |
| Emancipation | process by which a minor is freed from parental control based on specific criteria (the minor no longer requires parental guidance or financial support, fathered or gave birth to a child, or has reached the age of majority). |
| Emergency Medical Treatment and Active Labor Act | Emergency Medical Treatment and Active Labor Act; aka Federal Anti-Dumping Statute; legislation enacted in 1986/hospitals were refusing to treat patients w/o insurance and even transferring them to other facilities and leaving them there |
| EOB | Explanation of Benefits; the former name of the Medicare Summary Notice, which is the remittance advice. |
| Evaluation and management (E&M) | both the process of and the charge for examining a patient and formulating a treatment plan. |
| Fair Credit Billing Act | amendment to the Truth in Lending Act; it protects consumers from inaccurate or unfair practices by issuers of open-ended credit |
| Fair Debt Collection Practices Act | legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions of debt collection practices. |
| false | type of skip generally caused by clerical error at the time of registration, such as transposed numbers in the street address, an incorrect zip code, or incomplete information. |
| False Claims Act | legislation that prohibits making a false record or statement to get a false/fraudulent claim paid by the government, submission of false/fraudulent claims, and conspiring to have false |
| FDA | Food and Drug Administration; one of the DHHS Operating Divisions. |
| FDCPA | Fair Debt Collection Practices Act; legislation enacted as the result of evidence that debt collectors were using abusive, deceptive, and unfair collection practices; it imposes strict limitations and prohibitions on debt collection practices. |
| Federal Anti-Dumping Statute | Emergency Medical Treatment and Active Labor Act (EMTALA); legislation enacted in 1986 in response to concerns that hospitals were refusing to treat patients without insurance and even transferring them |
| FOIA | Freedom of Information Act. |
| fraud | the intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization |
| GAAP | generally accepted accounting principles |
| HCFA | Health Care Financing Administration; the former name for the Centers for Medicare and Medicaid Services |
| HCPCS | Healthcare Common Procedure Coding System; the federal government equivalent to the CPT system. |
| Health Care Fraud Prevention and Enforcement Action Team | HEAT, a team that uses government resources to help prevent fraud, waste, and abuse in both the Medicare and Medicaid programs. |
| Healthcare Power of Attorney | also known as Durable Power of Attorney for Healthcare; a document that designates someone else (known as a healthcare surrogate, agent, or proxy) to make decisions on the patient's behalf if he or she is unable to do so |
| HICN | Medicare Health Insurance Claim Number. |
| Hill-Burton Act | Hospital Survey and Construction Act; legislation designed to assist hospitals by providing loans for construction projects once the hospitals were operational, funds that were borrowed were to be paid back in the form of charity; known as Title 1. |
| HIPAA | Health Insurance Portability and Accountability Act of 1996; also known as the Kennedy-Kassenbaum Bill; it created federal standards for insurers, HMOs, and employer plans including those who are self-insured. |
| HMO | Health Maintenance Organization; one of five types of Medicare Advantage Plans in which members must generally get healthcare from providers in the plan's network. |
| home health care | preventative, supportive, rehabilitative, or therapeutic care provided to a patient at home; to be reimbursed by the Medicare program, a physician must certify that the patient is home bound |
| hospice care | coordinated, palliative care provided to terminally ill patients and their families by nonprofit organizations. |
| HRSA | Health Resource and Services Administration; one of DHHS Operating Divisions. |
| HSA | Health Savings Account (formally known as Medical Savings Account, or MSA). |
| I-Bill | an itemized statement. |
| ICD | International Classification of Diseases; a standard transaction set used for 1)chief complaint or diagnosis for professional services and inpatient procedures, and 2) for diagnosis |
| ICD-10 | the newest version of the International Classification of Diseases |
| IEQ | Initial Enrollment Questionnaire; a questionnaire mailed about three months before patients become entitled to Medicare; it asks about any other healthcare coverage that may be primary to Medicare. |
| IHS | Indian Health Service; on of the DHHS Operating Divisions |
| implied consent - by law | consent that occurs in a situation where the patient is unconscious and is taken to the emergency room; the law allows treating the patient. |
| implied consent - in fact | consent by silence; the patient implies consent to the treatment by not objecting |
| imprest | petty cash. |
| indigent | an individual with no means of paying for services or treatments, who is not eligible for Medicaid or another public assistance program. |
| informed consent | consent given when the risks and benefits of a treatment are understood and the patient makes an informed decision whether to receive that treatment |
| initial preventive physical examination (IPPE) | the "Welcome to Medicare Physical Exam" that is offered to each beneficiary once in a lifetime. |
| initiation | the beginning of the treatment for a new encounter or a new plan of care; one of the times when a triggering event for an ABN can occur. |
| intentional | a type of skip in which someone avoids paying bills by changing his or her name, or intentionally giving false information. |
| involuntary bankruptcy | bankruptcy in which a debtor can be placed under Chapter 7 or 11 if the debtor has 12 or more creditors, three of which have claims in excess of $5,000 each and are willing to force the issue, or one creditor owed at least $10,775. |
| IPPS | Inpatient Prospective Payment System. |
| Joint Commission, The (TJC) | the organization that accredits hospitals; formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program |
| judgment | a legally verified claim against a debtor; a legal right to collect a debt that can be used to obtain a lien. |
| Kennedy-Kassenbaum Bill | another name for the Health Insurance portability and Accountability Act of 1996 (HIPAA); it created federal standards for insurers, HMOs, and employer plans including those who are self-insured |
| Local Coverage Determination (LCD) | policies developed by Medicare area contractors that specify criteria for services and show under what clinical circumstances an item or service is considered to be reasonable, necessary, and appropriate |
| lien | a recorded claim against real or personal property; if the property is sold, the creditor must be paid out of the proceeds of that sale. |
| living will | a document that specifies what treatments a patient does and does not wish to receive it; it means that difficult decisions about future care are made while the person is alert; |
| long term care | care generally provided to the chronically ill or disabled in a nursing facility or rest home; among the services provided by nursing facilities are 24-hour nursing care |
| LTR | lifetime reserve. |
| MAAC | maximum allowable actual charge |
| MCE | Medicare Code Editor; software that edits claims to detect incorrect billing data that is being submitted |
| MDS | Minimum Data Set; part of the federally required process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes; the MDS then determines the Resource Utilization Group (RUG) and hence the payment. |
| Medicaid | a health insurance program for certain low-income people; it is funded and administered through a state-federal partnership. |
| Medicare | a health insurance program for the elderly (age 65 or older) and those under age 65 who have permanent disabilities or end state renal disease (ESRD). |
| Medicare Advantage Plans | another name for Medicare Part C; managed care coverage provided by private insurance companies approved by Medicare. |
| Medicare Participating Physician Program | a program that enables providers to accept assignment of benefits. |
| Medicare Secondary Payer (MSP) | laws that shifted costs from the Medicare program to other sources of payment; MSP information is gathered from each beneficiary to determine the proper coordination of benefits. |
| Medicare Summary Notice (MSN) | a remittance advice; formally called the Explanation of Benefits (EOB) |
| Medigap | also known as Medicare supplemental insurance; health insurance sold by private insurance companies to fill in the "gaps" in coverage (like deductibles, coinsurance, and copayments) under the Original Medicare Plan |
| MIC | Medicaid Integrity Contractors; review, audit, and educate providers to combat fraud and abuse. |
| midnight census | the number of patients in the hospital at midnight census; determined from the census count for the previous midnight, minus and discharges, plus an admissions, plus/minus any status changes |
| MSN | Medicare Summary Notice; a remittance advice; formerly called the Explanation of Benefits (EOB). |
| MSP | Medicare Secondary Payer; laws that shifted costs from the Medicare program to other sources of payment; MSP information is gathered from each beneficiary to determine the proper coordination of benefits |
| MSP Questionnaire | a questionnaire completed on an ongoing basis to help determine if Medicare is primary or secondary; it asks about employment, accidents, and several other relevant subjects. |
| MTF | Military Treatment Facility. |
| MUE | Medically Unlikely Edit; an automated edit for HCPCS/CPT codes for services rendered by a provider to a single beneficiary on the same date of service; it helps to prevent inappropriate payments due to clerical entries |
| MVPS | Medicare Volume Performance Standard; the element of the Resource Based Relative Value Scale (RBRVS) for the rates of increase in Medicare expenditures for physician services |
| NAS | Non-Availability Statement; a requirement before any non-emergent inpatient services may be provided to a Tricare Extra or Standard eligible beneficiary by a non-Military Treatment Facility (MTF). |
| National Correct Coding Initiative (NCCI) | a Medicare initiative to promote correct coding methodologies and strive to eliminate improper coding; it dentifies mutually exclusive CPT-4 and HCPCS codes or those that should not be billed together. |
| National Coverage Determination (NCD) | Medical review policies issued by CMS which identify specific medical items, services, treatment procedures, or technologies that can be covered and paid for by the Medicare Program |
| Navigators | individuals who help consumers fill out applications for health coverage through the Marketplace; they help determine if consumers qualify for programs to help lower their costs. |
| NIH | National Institutes of Health; one of the DHHS Operating Divisions. |
| non-definitive LCD/NCD | a policy that provides potential coverage circumstances, but most likely does not provide specific diagnoses, signs, symptoms, or ICD-9-CM codes that will be covered on non-covered; |
| non-Navigators | individuals who perform the same functions as Navigators but only in a state-based Marketplace or state partnership Marketplace. |
| non-standard claim | a claim with extraneous attachments in lieu of data entered correctly in the claim form. |
| notifier | CMS' name for an entity that issues ABNs. |
| NPI | National Provider Identification; a unique identifier for covered healthcare providers. |
| NPP | non physician practitioner. |
| NUBC | National Uniform Billing Committee; the entity that determined the data elements used in the UB-04 final format as a cooperative effort with the American Hospital Association (AHA). |
| Obamacare | one of the common names for the Patient Protection and Affordable Care Act, PPACA. |
| OBRA | Omnibus Budget Reconciliation Act (OBRA) of 1989; it provided for the Resource Based Relative Value Scale (RBRVS) as a payment reform provision. |
| observation | observation services furnished on a hospital premises, including use of a bed and periodic monitoring by a hospital's nursing staff; services usually do not exceed 24 hours |
| office | care provided in a practitioner's place of business; a practitioner may be a medical doctor, podiatrist, chiropractor, dentist, advanced practice nurse |
| OIG | Office of Inspector General; one of the entities, along with the Department of Justice, that coordinates fraud and abuse control; it also has identified seven elements of a compliance plan |
| ordering physician | a physician who orders non physician services for a patient, such as diagnostic x-rays. |
| Part A | the hospital insurance component of Medicare that helps pay for medically necessary inpatient hospitalization, care in a SNF following a three-day hospital stay, home health care, hospice care, and blood |
| Part B | the medical insurance component of Medicare that helps pay for doctor services, outpatient hospital care, and some other medical services that Part A does not cover |
| Part C | also known as Medicare Advantage Plans; managed care coverage provided by private insurance companies approved by Medicare. |
| Part D | the component of Medicare that helps pay for prescription drugs. |
| PAT | pre-admission testing; the diagnostic medical screening of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitability. |
| Patient Bill of Rights | a development by the American Medical Association that guarantees a patient the right to receive courteous, considerate, respectful treatment in a clean/safe environment |
| PCP | primary care physician. |
| per diem | Latin for "for each day"; a payment methodology in which providers are paid a predetermined amount for each day an inpatient is in the facility, regardless of actual charges or costs incurred. |
| percentage of occupancy | the ratio of actual patient days to the maximum patient days as determined by bed capacity |
| physician extender | physician assistant, nurse practitioner, etc. |
| PPO | Preferred Provider Organization; one of five types of Medicare Advantage Plans in which members can see any doctor or provider that accepts Medicare and they don't need a referral to see a specialist |
| PPS | prospective payment system. |
| pre-certification | the process of obtaining authorization from an insurance company review organization approving the medical necessity of a hospitalization. |
| Privacy Act of 1974 | legislation that governs patient confidentiality and provides safeguards against an invasion of privacy through the misuse of records by federal agencies |
| PSA | Physician Scarcity Area. |
| PSDA | Patient Self Determination Act of 1990; legislation that ensures that patients understood their right to participate in decisions about their own healthcare |
| QIO | Quality Improvement Organization; part of a CMS program to monitor and improve utilization and quality of care for Medicare beneficiaries. |
| RBRVS | Resource Based Relative Value Scale/payment reform provision comprising three major elements: fee schedule for payment of phys services/based on the (RVU)/(MVPS) for the rates of increase in Medicare expenditures for phys services |
| reduction | a decrease in the frequency or duration of care; one of the times when a triggering event for an ABN can occur. |
| referring physician | a physician who requests an item or service for a beneficiary for which payment may be made under Medicare. |
| Regulation Z | another name for Title I of the Consumer Credit Protection Act, or in the Truth in Lending Act; it requires disclosure of information before credit is extended. |
| remittance advice | another name for the Medicare Summary Notice; formerly called the Medicare Explanation of Benefits (EOB). |
| Resource Utilization Group (RUG) | a system to determine the payment rate for most skilled nursing care; |
| respite care | short-term, temporary custodial care that allows a family member or other unpaid caregiver to get relief from caring for a physically frail or dependent person at home. |
| RVU | relative value unit; the basis for the fee schedule for payment of physician services that is one of the elements of the Resource Based Relative Value Scale (RBRVS). |
| SAMHSA | Substance Abuse and Mental Health Services Administration; one of the DHHS Operating Divisions. |
| skip | a debtor who cannot be located by a creditor; there are three types; intentional; unintentional, and false. |
| SNF | skilled nursing facility; a separate wing of the hospital, a nursing home, or a freestanding facility; to qualify for SNF coverage, Medicare requires a person to have a hospital inpatient for at least three consecutive days |
| spell of an illness | also known as the benefit period; the period of time that begins when a beneficiary enters the hospital and ends 60 days after discharge from the hospital or from a SNF. |
| statue of limitations | the amount of time in which a claim must be collected before it is deemed paid or satisfied. |
| superbill | an invoice used to document the services ordered or rendered during a patient visit; it is often referred to as a face sheet |
| termination | a discontinuation in the services being provided; one of the times when a triggering event for an ABN can occur. |
| Title XVIII | Medicare |
| Title XIX | Medicaid |
| TJC | The Joint Commission; the organization that accredits hospitals; accreditation is extremely important for hospitals as it is a requirement of participation in the Medicare program. |
| tort liability | a liability for an injury or wrongdoing by one person to another resulting from a breach of legal duty |
| TPA | third party administrator. |
| Tricare | a regionally-managed healthcare program for active duty and retired members of the uniformed services, their families, and survivors. |
| triggering event | an event that occurs during initiation, reduction, or termination of a course of treatment that triggers the need for an ABN. |
| Truth in Lending Act | another name for Title I of the Consumer Credit Protection Act; also known as Regulation Z; it requires disclosure of information before credit is extended. |
| Two Midnight Rule | CMS guideline stating that when a physician expects a Medicare patient to remain in the hospital for a least two midnights, the physician should write an inpatient admission order |
| UB-04 | the uniform bill required of hospital inpatient and outpatient departments |
| UCR | usual, customary, and reasonable; a method to determine the value of services used by many third party payers; it relies on physician-charge data accumulated over time; |
| unintentional | a type of skip in which someone moves or changes residence and fails to notify creditors; a forwarding address is normally available. |
| unprocessable | a claim that is considered incomplete or invalid due to missing claim form data elements. |
| UR | also known as Case Management; an area that performs critical tasks during registration and a patient's stay, |
| V code | a type of ICD-9 code used when services or visits relate to circumstances other than disease or injury. |
| V A | the U.S. Department of Veterans Affairs. |
| VCIS | voice case information system; a telephonic system used to perform an on-site check at the bankruptcy clerk's office. |
| workers' compensation | a plan that covers injuries sustained by a worker in the course of performing his or her job duties. |
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