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Definition
| A duplicate data file which may be used to restore information in the event of a power failure or other data loss. |
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Definition
| A group of claims for different patients set at the same time from one facility. |
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Definition
| A provider who sends health information in electronic form in connection with a transaction covered by HIPAA. |
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Definition
| This "secret code" makes data unreadable to unauthorized parties. |
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Definition
| A combination of letters and/or numbers that each individual is assigned to access computer data. |
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Definition
| A request for payment, based on a review, of a claim that has been incorrectly paid or denied by an insurance company. |
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Definition
| An evaluation done by a group of unbiased practicing physicians to judge the medical necessity of a requested procedure. |
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Definition
| To send another request for payment of an overdue bill. |
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Term
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Definition
| When a claim has not been processed yet because the insurance company required additional information. |
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Term
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Definition
| A written request made to an insurance company for the status of a claim. |
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Definition
| The unpaid balances due from patients and third-party payers for services that have been rendered. |
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Term
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Definition
| The relationship between the total amount of money owed to the practice and the total amount of money collected. |
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Definition
| A willful act by an employee of taking possession of an employer's money. |
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Definition
| A person who takes possession of the assets of a deceased person and pays the claims of creditors. |
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Definition
| A court order attaching a debtor's property or wages to pay off a debt. |
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Definition
| Making no charge to anyone, patient or insurance, for medical care. |
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Definition
| A patient who owes a balance on his or her account and moves but leaves no forwarding address. |
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Term
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Definition
| The maximum time during which a legal collection suit may be rendered against a debtor. |
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Definition
| An asset or debt that has been determined to be uncollectible and is taken off the accounting books. |
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Definition
| A statement issued by a board or association verifying that a person meets professional standards. |
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Definition
| A resume that gives recent experiences first with dates and descriptive data for each job. |
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Term
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Definition
| A resume that summarizes the job skills as well as education and employment history. |
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Definition
| Formal education by a working professional to improve or maintain professional competence. |
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Term
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Definition
| A resume that states the qualifications or skills an individual is able to perform. |
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Term
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Definition
| Exchanging information or services among individuals, groups, or institutions and making use of professional contacts. |
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Term
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Definition
| Incidents or practices, not usually considered fraudulent but are inconsistent with generally accepted behavior. |
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Term
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Definition
| An independent organization that receives and processes medical claims from multiple medical practices. |
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Term
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Definition
| A process of meeting regulations, recommendations, and expectations of federal and state agencies that pay for health care. |
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Term
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Definition
| The release of information, in any manner, outside the office. |
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Term
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Definition
| The deliberate misrepresentation of the facts to deceive others. |
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Term
| protected health information |
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Definition
| Any information that identifies an individual and describes his health status, age, sex, ethnicity, or other demographic information. |
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Term
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Definition
| An agreement for settling a work comp case after the patient has been declared permanent and stationary, in which no future medical expenses will be covered by the workers' comp insurance. |
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Term
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Definition
| The science of fitting the physical needs of the worker to their work place. |
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Term
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Definition
| In workers' compensation, usually refers to a specific incident or accident that causes damage or loss to a worker. |
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Term
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Definition
| A legal promise to pay a debt owed by the patient to the physician out of any proceeds received on the case. |
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Term
| occupational illness or disease |
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Definition
| In workers' compensation, usually refers to a medical condition caused by long term exposure to environmental factors. |
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Term
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Definition
| A phrase used when a workers' compensation patient condition has become stabilized and no further improvement or worsening is expected. |
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Term
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Definition
| Videotapes made without the knowledge of the patient; used to prove insurance fraud against an injured worker |
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Term
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Definition
| The status of an injured worker, who for a specified amount of time, is incapable of performing their normal work duties. |
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Term
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Definition
| If a person, or company, can be held liable to pay the medical costs for an injury or disability, occurring during their job,caused by an entity not connected with the employer. |
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Term
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Definition
| The initial period of time that an injured person must wait before they are eligible to receive the financial benefits. |
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Term
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Definition
| Therapy designed to simulate real job duties in order to build up strength and improve endurance. |
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Term
| disability income insurance |
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Definition
| Pays money to the insured patient when they are disabled, but not due to a work-related accident or condition. |
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Term
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Definition
| Provisions written into the insurance contract denying coverage or limiting the scope of coverage, for certain conditions or services |
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Term
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Definition
| An illness or injury that prevents an insured person from performing one or more of the functions of his regular job. |
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Term
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Definition
| The payment of partial benefits when the insured is not totally disabled. |
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Term
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Definition
| Program for long term disability monthly benefits to workers and self-employed persons who meet certain conditions set by Social Security |
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Term
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Definition
| Insurance provisions that will increase monthly benefits under certain conditions. |
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Term
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Definition
| An illness or injury which is expected to continue for the lifetime of the injured worker that to some extent affects his earning capacity. |
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Term
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Definition
| In insurance, the insured is determined to be unable to perform the major duties of his or her specific condition. |
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Term
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Definition
| Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests. |
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Term
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Definition
| When physicians see a high volume of patients - more than medically necessary - to increase revenue. |
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Term
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Definition
| The practitioner who oversees and controls the care of patients in a managed health care plan. |
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Term
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Definition
| If the patient's services are more than a certain amount, the physician can begin asking the patient to pay fee for service. |
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Term
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Definition
| Transferring the sickest, high-cost patients to other physicians or facilities. |
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Term
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Definition
| A process of reviewing the medical necessity for services and providers' use of medical care resources. |
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Term
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Definition
| Aged, blind, or disabled individuals who meet financial eligibility for state financial aid, like AFDC, plus medical coverage. |
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Term
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Definition
| A federally aided, state operated program that provides medical benefits for low-income persons in need of medical care. |
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Term
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Definition
| Persons who need financial assistance in order to meet their medical costs, but do not qualify for cash aid. |
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Term
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Definition
| The amount a patient must pay each month before Medicaid will pay anything. |
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Term
| Advance Beneficiary Notice |
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Definition
| An agreement signed by the patient, before a service is rendered, saying that the doctor thinks the service may be denied by Medicare and that the patient would be responsible. |
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Term
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Definition
| An organization under contract to the government that handles claims under Medicare. |
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Term
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Definition
| The maximum fees that nonparticipating physicians may bill Medicare patients. |
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Term
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Definition
| The diagnosis that proves the services rendered were consistent with the standards of good medical practice. |
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Term
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Definition
| When the person who reports the fraud to Medicare gets a percentage of the judgment against a provider, as an award. |
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Term
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Definition
| An individual entitled to receive insurance benefits. |
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Term
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Definition
| An area, defined by zip code, that is approximately 40 miles in radius from the nearest military hospital. |
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Term
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Definition
| An electronic data base used to verify beneficiary eligibility for TRICARE. |
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Term
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Definition
| A program of medical care for military (TRICARE) personnel, that provides medical coverage without the patient paying premiums. |
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Term
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Definition
| In TRICARE, the military person, who brings the insurance to the beneficiary. |
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Term
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Definition
| A part of the expected payment to the physician that is taken out and saved until the end of the year, to be refunded to the provider if he comes in under budget. |
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Term
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Definition
| An HMO that limits the patient's choice of personal physician to doctors contracted with that HMO. |
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Term
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Definition
| The amount a par provider agrees to accept as payment in full. |
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Term
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Definition
| A specialized supplemental insurance policy designed to cover the deductible and coinsurance amount left over after Medicare pays. |
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Term
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Definition
| A state program designed to help children under 21 who have certain medical conditions. |
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Term
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Definition
| The amount of actual money available to the practice at any given time. |
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Term
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Definition
| Standards of conduct generally accepted as a moral guide for behavior. |
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Term
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Definition
| Customs, rules of conduct, courtesy, and manners of the medical profession. |
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Term
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Definition
| An individual cross-trained to provide more than one function. |
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Term
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Definition
| A physician's liability in certain cases for the wrongful acts of his employees. |
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Term
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Definition
| A transfer of an individual's legal right to collect an amount payable under an insurance contract. |
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Term
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Definition
| When physicians are paid a fixed, per person amount, per patient enrolled at a given time, regardless of how many visits or what kind of visits. |
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Term
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Definition
| A percentage of the insurance allowed amount that the patient pays for services. |
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Term
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Definition
| A specific dollar amount that must be paid by the insured before a medical insurance plan begins covering health care costs. |
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Term
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Definition
| An individual who promises to pay the medical bill by signing a form agreeing to pay. |
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Term
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Definition
| The physician has contractual agreement with an insurance plan to render care to eligible patients, bill the insurance directly, and accept the allowed amount as payment in full. |
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Term
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Definition
| Finding out if a particular type of service is covered by this insurance plan and finding out if it is considered medically necessary. |
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Term
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Definition
| Finding out the maximum amount an insurance plan will pay for a particular service if the patient is determined eligible, the service is covered, and the service is considered medically necessary. |
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Term
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Definition
| When a patient has more than one insurance policy it has to be determined which insurance is to be billed primary and which to be billed secondary so there is no overlap of payments. |
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Term
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Definition
| Also known as the subscriber, member, policy holder…etc. This is the person who has the insurance. |
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Term
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Definition
| Services rendered by a physician whose opinion or advice is requested by another physician regarding a particular issue. |
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Term
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Definition
| A patient who has not received services by this physician, or another physician of the same specialty, in the same group practice, within the last 3 years. |
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Term
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Definition
| The transfer of the total care or specific care of a patient from one physician to another. |
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Term
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Definition
| The presence of an underlying disease or illness at the time of treatment. |
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Term
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Definition
| Identification number issued by the IRS for income tax purposes. |
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Term
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Definition
| A lifetime, 10-digit identification number that will be used by a practitioner no matter wher in the United States he/she practices. |
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Term
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Definition
| The claim contains technical errors that must be corrected before it can be processed. |
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Term
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Definition
| A claim that cannot be paid because of an error, eligibility issue, non-covered services, etc. |
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Term
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Definition
| The universal claim form used for all professional billing. |
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Term
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Definition
| Finding out if a particular type of service is covered by this insurance plan. |
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