question

accept assignment

answer

a term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided

question

account receivable

answer

records of the payments owed to the organization by outside entities such as third party payers and patients

question

administrative services only (ASO) contracts

answer

an agreement between an employer and an insurance organiztion to adminster the employer's self-insured health plan

question

Advance Beneficiary Notice of Noncoverage (ABN)

answer

a statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being done, that Medicare may not reimbure the provider for the service, wherein the patient indicates that he will be responsible for any charges

question

all patient DRGs (AP-DRGs)

answer

a case mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes

question

all patient refined DRGs (APR-DRGs)

answer

a case mix system develped by 3M and sued in a number of state reimbursement systesm to classify non-Medicare discharges for reimbursement purposes

question

ambulatory payment classification (APC) system

answer

hospital outpatient prospective payment system (HOPPS) syste. within a group, the diagnoses and procedures are similar in tersm of resources used, complexity of illness and conditions represented. a singel payment is made for the outpatient services provided.

question

ambulatory surgery center (ASC)

answer

under Medicare, it is a facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accoutnig systems. ahs as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation

question

auditing

answer

the performance of internal and/or external reviews to identify variations from established baselines

question

balance billing

answer

a reinbursment method that allows providers to bill patients for charges in exces of the amount paid by the patients' health plan or other third party payer

question

balanced budget refinement act of 1999 (BBRA)

answer

the amended version of the Balanced Budget Act of 1997 that authorizes implementatino of a per discharge prospective payment system for care provided to Medicare beneficiaries by inpatient rehabilitation facilities

question

blue cross and blue shield (BC/BS)

answer

the first prepaid healthcare plans in the United States;

question

BC/BS federal employee program (FEP)

answer

a federal program that offers a fee for service plan with preferred provider organizations and a point of service product

question

bundled payments

answer

a category of payments made as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time periodl. they include multiple services and may include multiple providers of care.

question

capitation

answer

...a method of healthcare reimbursement in which an insurance carrier prepays a physician, hospital, or other healthcare provider a fixed amount for a given population without regard to the actual number or nature of healthcare services provided to the population

question

case mix group

answer

...the 97 function related groups into which inpatient rehabilitation facility discharges are classifed on the basis of the patient's level of impairment, age, comorbidities, functional ability, and other factors

question

case mix group (CMG) relative weights

answer

...factors that ccount fo rhte variance incost per discharge and resource utuilization among case mix groups

question

case mix index

answer

...the average relative weight of all cases treated at a given facility ior by a given physician, which reflects the recource intensity or clinical severity fo a specific group in relation to the other groups int eh classification system; calculated by dividing the sum of the weights of diagnosis related groups for patients discharged during a given period divided by the total number of patients discharged

question

categorically needy eligibility groups (Medicaid

answer

...categories of individuals to whom states must provide coverage under the federal Medicaid program

question

centers for Medicare and Medcaid services (CMS)

answer

...the division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administereing the Medicare program and the federal port5ion of the Medicaid program

question

chargemaster

answer

...a financial manager form that contains information about the organization's charges for the healthcare services it provides to patients

question

civilian health andmedical program of teh uniformed services (CHAMPUS)

answer

...a federal program providing supplementary civilian sector hospital and medical services beyond that which is available in military treatment facilities to military dependents, retirees, and their dependents, and certain other.

question

civilian health and medical program veterans affairs (CHAMPVA)

answer

the federal healthcare benefits program for dependents of veteran rated by th eVeterans Administration as having a total and permanent disability, fo rsurvivors of veterans who died from VA-rated service connected conditions or who were rated permanently and toatlly disabled at the time of death from a VA rated service connected condition, and for survivors of persons who died in the line of duty

question

claim

answer

...itemized statement of heatlhcare services and their costs provided by a hospital, physician's office, or other healthcare provider; submitted for reimbursement to the healthcare insurance plan by either the insured party or by the provider

question

CMS-1500

answer

...the universal insurance claim form developed and approved by the American Medical Association and teh Centers for Medicare and Medicaid Services; physicians use it to bill Medicare, Medicaid, and private insurers for services provided

question

coinsurance

answer

cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met

question

comorbidity

answer

a medical condition that coexists with the priamry cause for hospitalization an daffects the patient's treatment and length of stay

question

compliance

answer

...the process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or thehealthcare organization's ehtical and business policies 2. the act of adhering to oficial requirements

question

compliance program guidance

answer

...the information provided by the Office of the Inspector General fo the Department of Health and Human Services to help healthcare organizations develop internal controls that promote adherence to applicable federal and state guidelines

question

complication

answer

a medical condition that arises during an inpatient hospitalization

question

coordination of benefits (COB) transaction

answer

...the electronic transmission of claims and /or payment information from a healthcare provider to a health plan for the purpose fo determining relative payment responsibilities

question

cost outlier

answer

exceptionally high costs associated with inpatient care when compared with other cases in teh same diagnosis related group

question

cost outlier adjustment

answer

additional reimbursement for certain high cost home care cases boased on teh loss sharing ratio of costs in excess of a threshold amount for each homoe health resource group

question

current procedural terminology (CPT)

answer

...a comprehensive, descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by physicians; published and jupdated annually by teh Americna Medical Association

question

department of health and human services (HHS)

answer

...the cabinet level federal agnecy that oversees all fo the health and human services related activities of the federal government and adminsters federal regulations

question

diagnosis related groups (DRGs)

answer

...a unit of case mix clasifications adopted by the federal government and some other payers as a prospective payment mechanism for hospital inpatients in which diseases aer placed into groups because realted diseases and treatments ten to consume similar amounts of heatlhcare resources and incur similar amounts of cost; in the Medicare and Medicaid programs, one of the more than 500 diagnostic classifications in which cases demonstrate similar resource consumption and lenght of stay patterms

question

discharge planning

answer

...the process of coordinating the activites related to the release of a pateitn when inpatient hospital care is no longer needed

question

discounting

answer

the application of lower rates of payment to multiple surgical procedures performed during the same operative session under the outpatient prospective payment system; the application of adjusted rates of payment by preferred provider organizations

question

DRG grouper

answer

...a computer program that assigns inpatient cases to diagnosis-related groups an ddetermines the Medicare reimbursement rate

question

employer based self insurance

answer

...an umbrell term used to describe health plans that are funded directly by employers to provide coverage for their employees exclusively in which employers establish accounts to cover their employees' medical expenses and retain control over the funds but vear teh risk of paying claims greater than their estimates

question

episode of care (EOC) reimbursement

answer

...a category of payments mae as lump sums to providers for all healthcare services delivered to a patient for a specific illness and/or over a specified time period;

question

exclusive provider organization (EPO)

answer

...hybrid managed care organization that provides benefits to subscribers only when healthcare services are performed by network providers; sponsored by self-insured (self-funded) employers or associations and exhibits characteristics of both health maintenance organizations and preferred provider organizations

question

explanation of benefits (EOB)

answer

...a statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan

question

external reviews (audits)

answer

...a performance or quality reivew conducted by a third-party payer or consultant hired for the purpose

question

federal employees' compensation act (FECA)

answer

...the legistlation enacted in 1916 to mandate workers' compensation for civilian federal employees, whose coverage includes lost wages, medical expenses, and survivors' benefits

question

fee schedule

answer

...a list of healthcare services and procedures (usually CPT/HCPCS codes) and the charges associated with them develpoed by a third party payer to represent the approved payment levels for a gien insurance plan; also called table of allowances

question

fee for service basis

answer

...a method of reimbursment through which providers retrospectively receive payment based oneither billed charges for servicers provided or on an annually updated fee schedule

question

fraud and abuse

answer

...the intentional and mistaken misrepresentation of reimbursement claims submitted to government sponsored health programs

question

geographic practice cost index (GPCI)

answer

...an index developed by the Centers for Medicare and Medicaid Services to measure the differences in resource costs among fee schedule areas compared to thenational average in teh three componenets of the relative value unit; physican work, practice expenses, and malpractice coverage.

question

global payment

answer

...a form of reimbursmeent used for radiological and other procedures that ocmbines teh professional an dtechnical components of the procedures and disperses payments as lump sums to be distributed between the physician and the healthcare facility

question

global surgery payment

answer

...a payment made for surgical procedures that includes the provision of all healthcare servicesw, from the treatment decision through postoperatie patient care

question

group health insurance

answer

...a prepaid medical plan that covers thehealthcare expenses of an organization's full time employees

question

group model HMO

answer

...a type of health plan in which an HMO contracts with an independent multispecialty physician group to provide medical services to members of the plan

question

group pracitce without walls (GPWW)

answer

...a type of managed care contract that allows physicians to maintain their own offices and share adminstyrative services

question

hard coding

answer

...the process of attaching a CPT/HCPCS code to a procedure located on teh facility's chargemaster so that the code will automatically be included ont he patient's bill

question

health maintenance organization (HMO)

answer

...entity that combines teh provision of healthcare insurance and the delivery of healthcare services, characterized by : 1. an organized healthcare delivery system to a geographic area, 2. a set of basic and supplemental health maintenance and treatment services, 3. voluntarily enrolled members, and 4. predetermined fixed, periodic prepayments for members' coverage

question

healthcare common procedure coding system (HCPCS)

answer

...an alphanumeric classification system that identifies healthcare procedures, equipment, and supplies for claim submissionpurposes; the three levels are as follows I, Current Procedural Terminology coes, developed by the AMA; II, codes for equipment, supplies, and services not covered by Current Procedural Terminolgoy codes as well as modifiers, that can be used with all levels of codes, developed by CMS; and III (eliminated December 31, 2003, to comply with HIPAA), local codes developed by regional Medicare Part B carriers an dused to report physician's services and supplies to Medicare for reimbursment

question

healthcare effectiveness data and information set (HEDIS)

answer

...a set of performance measures developed by the National Commission for Quality Assurance that are designed a provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans.

question

healthcare provider

answer

...a provider of diagnostic, medical, and suargical care as well as the services or supplies related to the health of anindividual an dany other peson or organization that issues reimbursement claims or is paid for healthcare in the normal course of business

question

home assessment validation and entry (HAVEN)

answer

...a type of data entry software used to collect Outcome an dAssessment Informatin Set (OASIS) data and then transmit them to state databases; imports and exports data in standard OASIS record format, maintains agency/patient/comployee information, enforces data integrity through rigorous edit checks, and provides comprehensive online help

question

home health agency (HHA)

answer

...a program or organization that proivdes a blend of homebased medical and social services to homebound patients and their families for teh purpose of promoting, maintaining, or restroing health or of minimizing the effects of illness, injury, or disability

question

home health prospecitive payment system HH PPS)

answer

...the reimbursement system developed by the Centers for Medicare and Medicaid Services to cover home health services provided to Medicare beneficiaries

question

home health resource group (HHRG)

answer

...a classification system with 80 hmoe health episode rates established to support the prospecitive reimbursement of covered home care and rehabilitation services provided to Medicare beneficiaries during 60 day episodes of care

question

hospice

answer

...an interdisciplinary program of palliative care and supportive services that addresses the physical, spiritaul, social, and economic needs of terminally ill patients and their families

question

hospital acquired condtions (HAC)

answer

...select, responably preventable conditions for which hospitals do not receive additional payment when one of the conditions was not present on admission

question

hospitalization insurance (HI) (Medicare Part A)

answer

...a federal program that covers teh costs associated weith inpatient hospitalization as well as other healthcare services provided to Medicare beneficiaries

question

indemity plans

answer

...health insurance coverage provided in the form of cash payments to patients or providers

question

independent practice association (IPA)

answer

...an open panel health maintenance organization that provides contract healthcare services to subscribers through independent pysicians who treat patients in their own offices; the HMO reimburses the IPA on a capitated basis; the IPA may reimburse the physicians on a fee for service or a capitated basis

question

indian health service (IHS)

answer

...the federal agnecy within the Department of Health and Human Services that is responsibel for providing federal healthcare services to American Indians and Alaska natives

question

inpatient psychiatric facility (IPF)

answer

...a healthcare facility that offers spychiatric medical care on an inpatient basis; CMS established a prospective payment system for reimbursing these types of facilities using the current DRGs for inpatient hospitals

question

inpatient rehabilitation facility (IRF)

answer

...a healthcare facility that specializes in providing services to patients who have suffered a disabling illness or injury in an effort to help them achieve or maintain their optimal level of functioning, self care and independence

question

inpatient rehabilitation validation and entry (IRVEN)

answer

...a computerized data entry system used by inpatient rehabilitation facilities

question

insured

answer

...a holder of a health insurance policy

question

insurer

answer

...an organiztion that pays healthcare expenses on behalf of its enrollees

question

integreated delivery system (IDS)

answer

...a system that combines the financial and lcinicasl aspects of ehalthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care

question

Integrated provider organization (IPO)

answer

...an organization that manages the delivery of healthcare services provided by hospitals, physicians, (employees of the IPO), and other healthcare organizations

question

long term care hospital (LTCH)

answer

...a hospital with an average length of stay of 25 days or more

question

low utilization payment adjustment (LUPA)

answer

...an alternative (reduced) payment made to home health agencies instead of teh home health resource group reimbursement rate when a patient recieves fewer than four home care visits during a 60 day episode

question

major diagnostic category (MDC)

answer

...under diagnosis related groups (DRGs), one of 25 categories based on single or multiple organ sysetms into which all disease and disorders relating to that system are classifeid

question

Major medical insurance

answer

...prepaid healthcare benefits that include a high limit for msot types of medical expenses and usually require a large deductible and sometimes place limits on coverage and charges

question

managed care

answer

...paymnet method in which the third party payer has implemented some provisions to control the costs of heatlhcare while maintaining quality care 2. systematic merger of clinical, financial, and administrative processes to manage access, cost, and quaity of heatlhcare.

question

management service organization (MSO)

answer

...an organiztion, ususally owned by a group of physicians or a hospital, that provides adminstrative and support services to one or more physician group practices or small hospitals

question

Medicaid

answer

...an entitlement program that oversees medical assistance for individuals and families with low incomes and limited resources; jointly funded between state and federal governments

question

medical foundation

answer

...multipurpose, nonprofit service organization for physicians and other healthcare providres at the local and county level; as managed care organizatoins, they have established preferred provider organizations, exclusive provider organizations, and management service organizations with emphases on freedom of choice and preservation of the physician patient relationship

question

medically needy option (Medicaid)

answer

...an option in the Medicaid program that allows states to extend eligibility to persons who would be eligible for Medicaid under one of the mandatory or optional groups buyt whose income and/or resources fall above the eligibility level set by their state.

question

Medicare

answer

...a federally funded health program estabished in 1965 to assist with the medical care costs of Americans 65 years and older as well as other individuals entitled to Social Security benefits owing to their disabilities

question

medicare administrative contractor (MAC)

answer

...newly established contracting entities that will administer Medicare Part A and Part B as of 2011

question

medicare advantage

answer

...optional managed care plan for Medicare beenficiaries who are entitled to Part and, enrolled in Part B, and live in an area with a plan/ types include health maintenance organization, point of service plan, preferred provider organization, and proivder sponsored organization.

question

medicare carrier

answer

...a health plan that processes Part B claims for services by physicians and medical suppliers

question

medicare fee schedule (MFS)

answer

...a feature of the resource-based relative value system that includes a complete list of the payments Medicare makes to physicians and other providers

question

medicare severity diagnosis-related groups (MS-DRGs)

answer

...the US government's 2007 revision of the DRG system, the MS-DRG system better accoutns for severity of illness and resource consumption

question

Medicare Summary Notice (MSN)

answer

...a summary sent to the patient from Medicare that summarizes all services provided over a period of time with an explanation of benefits provided

question

Medigap

answer

...a private insurance policy that supplements Medicare coverage

question

Minimum Data Set 3.0 (MDS)

answer

...a federally mandated standard assessment form that Medicare and/or Medicaid certified nursing facilities must use to collect demographic and clincial data on nursing home residents.

question

National Committee for Quality Assurance (NCQA)

answer

...a private, not for profit accreditation organization whose mission is to evaluate an dreport aon the quality of managed care organizations in the United States

question

National conversion factor (CF)

answer

...a mathematical factor used to convert relative value units into monetary payments for services provided to Medicare beneficiaries

question

National correct coding initiative (NCCI)

answer

...a series of codes edits on Medicare Part B claims

question

national uniform billing committee (NUBC)

answer

...the national group responsible for identifying data elements and designing the CMS-1500

question

network model HMO

answer

...program in which participating HMOs contract for services with one or more multispecialty group practices

question

network provider

answer

...a physician or another healthcare professional who is a member of a managed care network

question

nonparticipating providers

answer

...a healthcare provider who didi not sign a participation agreement with Medicare and so is not obligated to accept assignment on Medicare claims

question

omnibus budget reconciliation act (OBRA)

answer

...federal legislation passed in 1987 that required the Health Care Financing Adminstration ( now named the Centers for Medicare and Medicaid Services) to develop an assessment instrument (called the resident assessment instrument) to standardize the collection of patient data from skilled nursing facilities

question

outcomes and assessment information set (OASIS)

answer

...a standard core assessment data tool develped to measure the outcomes of adult patients receiving home health services under the Medicare and Medicaid programs

question

out of pocket expenses

answer

...healthcare costs paid by the insured after which the insurer pays a percentage of covered expenses

question

outpatient code editor (OCE)

answer

...a software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes ar ecorrect and appropriately represent the servcies provided.

question

outpatient prospective payment system (OPPS)

answer

...the Medicare prospective payment system used for hospital based outpatient services and procedures that is predicated onteh assignment of ambulatory payment classifications

question

packaging

answer

...a payment under the Medicare outpatient prospective payment system that includes items such as anesthesia, supplies, certain drugs, and the use of recovery and observation rooms

question

partial hospitalization

answer

...a term that refers to limited patients stays inteh hospital setting, typically as part foa transitional program to a less intense level of service

question

patient protection and affordable care act

answer

...a federal statue that was signed into law on March 23, 2010. along with the Health Care and Education Reconciliation Act of 2010, the Act is the product of the healthcare reform agenda of the Demoncratic 111th Congress and Obama administration

question

payer of last resort (Medicaid)

answer

...a Medicaid term that means that Medicare pays for the services provided to individuals enrolled in both Medicare and Medicaid until Medicare benefits are exhauseted and Medicaid benefits begin

question

payment status indicator (PSI)

answer

...an alphabetic code assigned to CPT/HCPCS codes to indicate whether a service or procedure is to be reimbursed under the Medicare outpaiten prospective payment system

question

per member per month (PMPM)

answer

...a type of manaed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes on year.

question

per patient per month (PPPM)

answer

...a type of manaed care arrangement by which providers are paid a fixed fee in exchange for supplying all of the healthcare services an enrollee needs for a specified period of time (usually one month but sometimes on year.

question

physician hospital organization (PHO)

answer

...an integreated delivery system formed by hospitals an dphysicians (usually through managed care contracts) that allows for cooperative activity but permits participants to retain some level of independence

question

point of service (POS) plan

answer

...a type of managed care plan in which enrollees are encouraged to select healthcare providers forma network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost

question

policyholder

answer

...an individual or entity that purchases healthcare insurance coverage

question

precertification

answer

...process of obtainign approval from a healthcare insurance company before receiving healthcare services

question

preferred provider organization (PPO)

answer

...a managed care arraqngement bassed ona contractual agreement between healthcare providers (professional and/or istitutional) an dto a defined population of enrollees at established fees that may or may not be a discount from usual and customary or reasonab le charges

question

premium

answer

...amount of money that a plicyholder or certificate holder must periodically pay an insurer in return for healthcare coverage

question

present on admission (POA)

answer

...a condition preent at the time of inpatient admission

question

Primary care physician (PCP)

answer

...the physiciabn who proivdes, supervises, and coordinates teh healthcare of a member and who manages referrals to other healthcare providers and utilization of healthcare services both inside and outside a managed care plan. 2. the physician who makes the initial diagnosis of a patient's medical condition

question

principle diagnosis

answer

...the disease or condition that wa present on admission, was the principal reason for admission, and received treatment or evalutaion during the hospital stay or visit.

question

principle procedure

answer

...the procedure preformed for the definitive treatment of a condition (as opposed to a procedure performed for diagnostic or exploratory purposes) or for care of a complication

question

professional component (PC)

answer

...the portion of a healthcare procedure performed by a physician 2. a term generally used in reference to the elements of radiological procedures performed by a physician

question

programs of all inclusive care for the elderly (PACE)

answer

...

question

prospective payment system (PPS)

answer

...a type of reimbursement system that is based on preset payment levels rather than actual charges billed after the service has been provided;

question

public assistance

answer

...a monetary subsidy provided to financially needy individuals

question

relative value unit (RVU)

answer

...a number asigned to a procedure that describes its difficulty and expense in relationship to other procedures

question

remittance advice (RA)

answer

...an explanation of payments made by third party payers

question

resident assessment instrument (RAI)

answer

...a uniform assessment instrument deveoped by the Centers for Medicare and Medicaid Services to standardize the collection of skilled nursing facility patient data

question

resident assessment validation and entry (RAVEN)

answer

...a type of data entry software develpoed by the Centers for Medicare and Medicaid Services for long-term care facilities and used to collect Minimum Data Set assessments and to transmit data to state databases

question

resource utilitzation groups, version IV (RUG-IV)

answer

...a case mix adjusted classification system based on Minimum Data Set assessments and used by skilled nursing facilities

question

resource based relative value sale (RBRVS)

answer

...a Medicare reimbursement system implemented in 1992 to compensate physicians according to a fee schedule predicated on weights assigend on the basis of the resources required to provide the services

question

respite care

answer

...a type or short term care provided during the day or overnight to idividuals in the home or institution to temporily relieve the family home caregiver

question

retrospective payment system

answer

...type of fee for service reimbursement in which providers receive recompense after health services have been rendered

question

recovery audit contractor (RAC)

answer

...organization contracted to detect and correct improper payments inthe Medicare Fee for Service (FFS) Program

question

revenue codes

answer

...a three or four digit number in the chargemaster that totals all items and their charges for printing on the form used for Medicare billing

question

skilled nursing facility prospective payment sysetm (SNF PPS)

answer

...a per diem reimbursement system implemented in July 1998 for costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare Part A beneficiaries

question

social security act

answer

...the federal legislation that originally established the Social Security program as well as unemployment compensation, and support for mothers and children, amended in 1965 to createthe Medicare and Medicaid programs

question

staff model HMO

answer

...a type of health maintenance that employs physicians to provide healthcare services to subscribers

question

state children's health insurance program (SCHIP)

answer

...the children's healthcare prgram im[plemented as part of the Balanced Budget Act of 1997;

question

state workers' compensation insurance funds

answer

...funds that proivde a stable source of insurance coverage for work-realted illnesses and injuries and serve to protect employers from underwriting uncertainties by making it possibel to have continuing availability of workers' compensation coverage

question

supplemental medical insurance (SMI) (Medicare Part B)

answer

...a voluntary medical insurance program that helps pay for physicians' services, medical services, an dsupplies not covered by Medicare Part A

question

tax equity and fiscal responsibility act of 1982 (TEFRA)

answer

...the federal legislation that modified Medicare's retrospective reimbursement system for inpatient hospital stays by requiring implementation of diagnosis related groups and the acute care prospective paymenbt systm

question

technical component (TC)

answer

...the portion of radiological and othe rprocedures that is facility based or nonphysician based

question

temporary assistance for Needy families (TANF)

answer

...a federal program that provides states with grants to be spent on time limited cash assistance for low income families, generally limiting a family's lifetime cash welfare benefits to a maximum of five years and permitting states to impose other requirements.

question

third party payer

answer

...an insurance company that reimburses healthcare providers and/or patients for the delivery of medical services

question

traditional fee for service reimbursement

answer

...a reimbursement method involving third party payers who compenstae providers after the healthcare services have been delivered; payment is based on specific services provided to subscribers

question

tricare

answer

...the federal healthcar program that provides coverage for the dependents fo armed forces personnel and for retirees receivign care outside military treatment facilities in which the federal government pays a percentage of the cost formerly known as teh Civilian Health and Medical Program of the Uniformed SErvices

question

tricare extra

answer

...a cost effective preferred provider network TRICARE option in which costs for healthcare are lower than fo the standard TRICARE program because a physician or medical specialist is selected from a network of civilian healthcare professionals whoparticipate in TRICARE Extra

question

tricare prime

answer

...a TRICARE progarm that provide the most comprehensive healthcare benefits at the lwoest cost of the three TRICARE options, in which military treatment facilities erve as the principal source of healthcare and aprimary care manager is assigned to each enrollee

question

tricare standard

answer

...a TRICARE program that allows elegible beneficiaries to choose any physician or healthcare provider, which permits the most flexiblity but may be the most expensive

question

UB-04 (CMS-1450)

answer

...the single standardized Medicare form for standardized uniform billing, scheduled for implementation in 2007 for hospital inpatients and outpatients; this form will also be used by the major third party payers and most hospitals

question

unbundling

answer

...the practice of using multiple codes to bill for the various individual steps in a singel procedure rather than using a single code that includes all of the steps of the comprehensive procedure

question

upcoding

answer

...

question

usual, customary, and reasonable (UCR) charges

answer

method of evaluating providers' fees in which the third party payer pays for fees that are usual in that providers' practice

question

veterans health administration

answer

...the component of the U.S.Department of Veterans Affiars that implements the medical assistance program of the VA

question

voluntary disclosure program

answer

...a progarm unveiled in 1998 by the Office of the Inspector General (OIG) that encourages healthcar providers to voluntarily report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs

question

workers' compensation

answer

...the medical and income insurance coverage for certain employees in unusually hazardous jobs.

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