contract between employer and health care facility (or physician) where specified medical services were performed for a predetermined fee that was paid on either a monthly or yearly basis. Preferred Provider Health Care Act of 1985. eased restrictions on preferred provider organizations (PPOs) and allowed subscribers to seek health care from providers outside of the PPO. second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor's office versus inpatient hospitalization). submitted for services provided to a baby under the mother's Medicaid identification number. implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. Start studying Understanding Health Insurance: A Guide to Billing & Reimbursement. founded in 1928 to improve the quality of medical records, and currently advances the health information management (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013. federal law passed in 1975 that helps consumers resolve billing issues with card issuers; protects important credit rights, including rights to dispute billing errors, unauthorized use of an account, and charges for unsatisfactory goods and services; cardholders cannot be held liable for more than $50.00 of fraudulent charges made to a credit card, protects information collected by consumer reporting agencies such as, Fair Credit and Charge Card Disclosure Act, amended the Truth in Lending Act, requiring credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-end credit and charge accounts and under other circumstances; this law applies to providers that accept credit cards, Fair Debt Collection Practices Act (FDCPA). seven-month period that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B. may be used only once during a patient's lifetime and are usually reserved for use during the patient's final, terminal hospital stay, denial of otherwise covered services that were found to be not "reasonable and necessary". Understanding Health Insurance: A Guide to Billing and Reimbursement Understanding Health Insurance, Eleventh Edition, is the essential learning tool you need when preparing for a career in medical insurance billing. specified low-income Medicare beneficiary (SLMB). 0 Reviews. maintained by the Food and Drug Administration (FDA); identifies prescription drugs and some over-the-counter products, abbreviation for the Latin phrase qui tam pro domino rege quam pro sic ipso in hoc parte sequitur, which means "who as well for the king as for himself sues I this matter." insurance claim or flat file used to bill institutional services, such as services performed in hospitals. Outcomes and Assessment Information Set (OASIS), group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality, Outpatient Prospective Payment System (OPPS). income guidelines established annually by the federal government. type of single-payer system in which the government owns and operates health care facilities and providers (e.g., physicians) receive salaries; the VA health care program is a form of socialized medicine. A notice sent by the insurance company that contains payment information about a claim. Medicare Drug Integrity Contractors(MEDIC) Program. organization of affiliated provider sites (e.g., hospitals, ambulatory surgical centers, or physician groups) that offer joint health care services to subscribers. software that edits outpatient claims submitted by hospitals, community mental health centers, comprehensive outpatient rehabilitation facilities, and home health agencies; the software reviews submissions for coding validity (e.g. requires that outpatient preadmission services provided by a hospital for a period of up to three days prior to a patient's inpatient admission be covered by the IPPS DRG payment for diagnostic services (e.g., lab testing) and therapeutic (or nondiagnostic) services, any patient with a diagnosis from one of ten CMS-determined DRGs, who is discharged to a post acute provider, is treated as a transfer case; this means hospitals are paid a graduated per diem rate for each day of the patient's stay, not to exceed the prospective payment, Inpatient Rehabilitation Validation and Entry (IRVEN). missing fifth digits) and coverage. Name: Understanding Health Insurance A Guide to Billing and ReimbursementAuthor: GreenEdition: 10thISBN-10: 1111035180ISBN-13: 978-1111035181 surveillance and utilization review subsystem (SURS), safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.
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