Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Ch. 9-12 Vocab
HIT Classification and Reimbursement
| Term | Definition |
|---|---|
| advance beneficiary notice of noncoverage (ABN) | Medicare form used to inform a patient that a service to be provided is not likely to be reimbursed by the program. |
| annual wellness visit (AWV) | A preventive service providing a health risk assessment and personal prevention plan. |
| carrier | Health plan; also known as insurance company, payer, or third-party payer. |
| Clinical Laboratory Improvement Amendments (CLIA) | Federal law establishing standards for laboratory testing performed in hospital-based facilities, physicians’ office laboratories, and other locations; administered by CMS. |
| Common Working File (CWF) | Medicare’s master patient/procedural database. |
| cost sharing | The insured’s deductible and coinsurance. |
| fiscal intermediary | Government contractor that processes claims for government programs; for Medicare, the fiscal intermediary (FI) processes Part A claims. |
| Health Professional Shortage Area (HPSA) | Medicare-defined geographic area offering participation bonuses to physicians. |
| incident-to services | Term for services of allied health professionals, such as nurses, technicians, and therapists, provided under the physician’s direct supervision that may be billed under Medicare. |
| initial preventive physical examination (IPPE) | Medicare benefit of a preventive visit for new beneficiaries. |
| Internet-Only Manuals | The Medicare online manuals that offer day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives. |
| limiting charge | In Medicare, the highest fee (115 percent of the Medicare Fee Schedule) that nonparticipating physicians may charge for a particular service. |
| local coverage determinations (LCDs) | Decisions by MACs about the coding and medical necessity of a specific Medicare service. |
| Medical Review (MR) Program | A payer’s procedures for ensuring that providers give patients the most appropriate care in the most cost-effective manner. |
| Medical Savings Account (MSA) | The Medicare health savings account program. |
| Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) | Legislation that redesigned the Medicare Part B reimbursement incentive and mandated the transition to the MBI. |
| Medicare administrative contractor (MAC) | Assigned by CMS to replace the Pt A fiscal intermediaries and the Pt B carriers; aka A/B MACs, handle claims and related functions for both Pts A/B within specified multistate jurisdictions. DME MACs handle claims for durable medequip billed by physicians |
| Medicare Advantage (MA) | Medicare plans other than the Original Medicare Plan. |
| Medicare Beneficiary Identifier (MBI) | Medicare beneficiary’s identification number. |
| Medicare card | Insurance identification card issued to Medicare beneficiaries. |
| Medicare Integrity Program (MIP) | The CMS program designed to identify and address fraud, waste, and abuse, which are all causes of improper payments. |
| Medicare Learning Network (MLN) Matters | An online collection of articles that explain all Medicare topics. |
| Medicare Modernization Act (MMA) | Short name for the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which included a prescription drug benefit. |
| Medicare Part A (Hospital Insurance [HI]) | The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home healthcare, and hospice care. |
| Medicare Part B (Supplementary Medical Insurance [SMI]) | The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies. |
| Medicare Part C | Managed care health plans offered to Medicare beneficiaries under the Medicare Advantage program. |
| Medicare Part D | Prescription drug reimbursement plans offered to Medicare beneficiaries. |
| Medicare Summary Notice (MSN) | Type of remittance advice from Medicare to beneficiaries to explain how benefits were determined. |
| Medigap | Insurance plan offered by a private insurance carrier to supplement Medicare Original Plan coverage. |
| national coverage determination (NCD) | Medicare policy stating whether and under what circumstances a service is covered by the Medicare program. |
| notifier | The provider who completes the header on an ABN. |
| Original Medicare Plan | The Medicare fee-for-service plan. |
| Quality Payment Program (QPP) | Two-track value-based reimbursement system designed to incentivize high quality of care over service volume. |
| recovery auditor program | A Medicare postpayment claim review program. |
| roster billing | Under Medicare, simplified billing for pneumococcal, influenza virus, and hepatitis B vaccines. |
| screening services | Tests or procedures performed for a patient who does not have symptoms, abnormal findings, or any past history of the disease; used to detect an undiagnosed disease so that medical treatment can begin. |
| United States Preventive Services Task Force (USPSTF) | Independent panel of nonfederal experts in prevention and evidence-based medicine that conducts scientific evidence review of a broad range of clinical preventive healthcare services and develops recs for primary care clinicians and health systems. |
| urgently needed care | In Medicare, a beneficiary’s unexpected illness or injury requiring immediate treatment; Medicare plans pay for this service even if it is provided outside the plan’s service area. |
| waived tests | Particular low-risk laboratory tests that Medicare permits physicians to perform in their offices. |
| Zone Program Integrity Contractor (ZPIC) | An antifraud agency that conducts both prepayment and postpayment audits based on the rules for medical necessity that are set by LCDs. |
| categorically needy | A person who receives assistance from government programs such as Temporary Assistance for Needy Families (TANF). |
| Children’s Health Insurance Program (CHIP) | Program offering health insurance coverage for uninsured children under Medicaid. |
| crossover claim | Claim for a Medicare or Medicaid beneficiary; Medicare is the primary payer and automatically transmits claim information to Medicaid as the secondary payer. |
| dual-eligible | A Medicare-Medicaid beneficiary. |
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) | Medicaid’s prevention, early detection, and treatment program for eligible children under the age of twenty-one. |
| Federal Medicaid Assistance Percentage (FMAP) | Basis for federal government Medicaid allocations to individual states. |
| Medicaid Integrity Program (MIP) | Program created by the Deficit Reduction Act of 2005 to prevent and reduce fraud, waste, and abuse in Medicaid. |
| MediCal | California’s Medicaid program. |
| medically needy | Medicaid classification for people with high medical expenses and low financial resources, although not sufficiently low to receive cash assistance. |
| Medi-Medi beneficiary | Person who is eligible for both Medicare and Medicaid benefits. |
| payer of last resort | Regulation that Medicaid pays last on a claim when a patient has other insurance coverage. |
| restricted status | A category of Medicaid beneficiary. |
| spenddown | State-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses. |
| Temporary Assistance for Needy Families (TANF) | Government program that provides cash assistance for low-income families. |
| Welfare Reform Act | Law that established the Temporary Assistance for Needy Families program in place of the Aid to Families with Dependent Children program and that tightened Medicaid eligibility requirements. |
| catastrophic cap | The maximum annual amount a TRICARE beneficiary must pay for deductible and cost share. |
| Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) | Government health insurance program for the families of veterans with 10 percent service-related disabilities |
| Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) | Replaced by TRICARE |
| cost-share | Coinsurance for a TRICARE or CHAMPVA beneficiary. |
| Defense Enrollment Eligibility Reporting System (DEERS) | The worldwide database of TRICARE and CHAMPVA beneficiaries. |
| Military Treatment Facility (MTF) | Government facility providing medical services for members and dependents of the uniformed services. |
| Primary Care Manager (PCM) | Provider who coordinates and manages the care of TRICARE beneficiaries. |
| Prime Service Area | Geographic area designated to ensure medical readiness for active-duty members. |
| sponsor | The uniformed service member in a family qualified for TRICARE or CHAMPVA. |
| TRICARE | Government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS. |
| TRICARE For Life | Program for beneficiaries who are both Medicare and TRICARE eligible. |
| TRICARE Prime | The basic managed care health plan offered by TRICARE. |
| TRICARE Select | The fee-for-service military health plan. |
| Admission of Liability | Carrier’s determination that an employer is responsible for an employee’s claim under workers’ compensation. |
| automobile insurance policy | A contract between an insurance company and an individual under which the individual pays a premium in exchange for coverage of specified car-related financial losses. |
| disability compensation program | A plan that reimburses the insured for lost income when the insured cannot work because of an illness or injury, whether or not it is work related. |
| Federal Employees’ Compensation Act (FECA) | A federal law that provides workers’ compensation insurance for civilian employees of the federal government. |
| Federal Insurance Contribution Act (FICA) | The federal law that authorizes payroll deductions for the Social Security Disability Program. |
| final report | A document filed by the physician in a state workers’ compensation case when the patient is discharged. |
| first report of injury | A document filed in state workers’ compensation cases that contains the employer’s name and address, employee’s supervisor, date and time of accident, geographic location of injury, and patient’s description of what happened. |
| independent medical examination (IME) | Examination by a physician conducted at the request of a state workers’ compensation office or an insurance carrier to confirm that an individual is permanently disabled. |
| liens | Written, legal claims on property to secure the payment of a debt. |
| Notice of Contest | Carrier’s notification of determination to deny liability for an employee’s workers’ compensation claim. |
| occupational disease or illness | Condition caused by the work environment over a period longer than one workday or shift; also known as nontraumatic injuries. |
| Occupational Safety and Health Administration (OSHA) | Federal agency that regulates workers’ health and safety risks in the workplace. |
| Office of Workers’ Compensation Programs (OWCP) | The office of the U.S. Department of Labor that administers the Federal Employees’ Compensation Act which covers work-related injuries of illnesses suffered by civilian employees of federal agencies. |
| personal injury protection (PIP) | Insurance coverage for medical expenses and other expenses related to a motor vehicle accident. |
| physician of record | Provider under a workers’ compensation claim who first treats the patient and assesses the level of disability. |
| progress report | A document filed by the physician in state workers’ compensation cases when a patient’s medical condition or disability changes; also known as a supplemental report. |
| Social Security Disability Insurance (SSDI) | The federal disability compensation program for salaried and hourly wage earners, self-employed people who pay a special tax, and widows and minor children with disabilities whose deceased spouse/parent would qualify for Social Security benefits if alive. |
| subrogation | Action by payer to recoup expenses for a claim it paid when another party should have been responsible for paying at least a portion of that claim. |
| Supplemental Security Income (SSI) | Government program that helps pay living expenses for low-income older people and those who are blind or have disabilities. |
| vocational rehabilitation | Retraining program covered by workers’ compensation to prepare a patient for reentry into the workforce. |
Created by:
shulukong
Popular Medical sets