CHAA Certification

When a provider agrees to accept the allowable charges as the full fee and cannot charge the patient the difference between the insurance payment and the provider's normal fee.

The Patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care.

A number assigned to each account. The number is used to identify the account and all charges and payments received.

Medical attention given to patients with conditions of sudden onset that demand urgent attention or care of limited duration when the patient's health and wellness would deteriorate without treatment. The care is generally short-term rather than long-term or chronic care.

A level of health care delivered to patients experiencing acute illness or trauma. Acute care is generally short-term less than 30 days.

Patients who are scheduled for services less than 24 hours in advance of the actual service time.

Insurance company representative

Costs associated with creating and submitting a bill for services, which could include, registration, utilization review, coding, billing, and collection expenses.

The process of third party payor notification of urgent/emergent inpatient admission within specified time as determined by payors which is usually within a 24 to 48 hour or next business day.

The first date the patient entered the hospital for a specific visit.

Word, phrase, International Classification of Disease (ICD9) code used by the admitting physician to identify a condition or disease from which a patient suffers and for which the patient needs or seeks medical care.

The physician who writes the order for the patient to be admitted to the hospital. The physician must have admitting privileges at the facility providing the health care services.

A notice that a care provider should give a Medicare beneficiary to sign if the services being provided may not be considered medically necessary and Medicare may not pay for them. The advanced beneficiary notice (ABN) allows the beneficiary to make a informed decision prior to services whether or not he/she wishes to receive services. ABNs are not routinely given to emergency department patients.

An advance directive is a written instruction relating to the provision of health care when a patient is incapacitated. It could include appointing someone to make medical decisions, a state expressing the patients wishes about anatomical gifts (like organ donation), and general statements about whether or not life-sustaining treatments should be withheld or withdrawn.

Among applicants for a given group or individual program, the tendency for those with an impaired health status, or who are prone to higher than average utilization of benefits to be enrolled in disproportionate numbers and lower deductible plans.

An alias is a name by which the patient is also known as or formerly known as.

A prospective hospital claims reimbursement system currently utilized by the federal government Medicaid program and the states of New York and New Jersey. APDRGs were designed to describe the complete cross section of patients seen in acute care hospitals. Approximately 639 APDRGs are defined according to the principal diagnosis, secondary diagnoses, procedures, age, birth weight, sex, discharge status. Each category has an established fixed reimbursement rate based on average cost of treatment within a geographic area. APRDRG's were developed to quantify the difference in demographic groups and clinical risk factors for patients treated in hospitals. This proprietary grouping system's (i.e. 3M) purpose is to obtain fair and accurate statistical comparisons between disparate populations and groups. Unlike the Diagnosis Related Group (DRG) reimbursement system which is intended to capture resource utilization intensity, the APRDRG system captures and relates the Severity of Illness and Risk of Mortality factors present as a result of a patient's disease and disorders and the interaction of those disorders. A form is signed by the Patient giving the healthcare provider authority to bill his/her insurance plan and receive payment. The form is generally presented and signed at the time of registration.

Letter, numbers, punctuation marks and mathematical symbols, as opposed to numeric which is numbers only. Term typically related to the kind of data accepted in a computer field or in coding.

Patient receives medical or surgical care in a outpatient setting that involves a broader, less specialized range of care. Ambulatory patients are generally able to walk and are not confined to a bed. In a hospital setting, ambulatory care generally refers to health care services provided on an outpatient basis.

A system of averaging and bundling using Current Procedural Terminology (CPT) procedure codes, Healthcare Common Procedure Coding System (HCPCS) Level II, and revenue codes submitted for payment. The APC system utilizes groups 142 of CPT codes based on clinical and resource similarity and establishes payment rates for each APC grouping. The 650 plus APCs are divided by significant procedures, medical services, ancillary services and partial hospitalization services. The APCs are similar clinically, by resources used and cost. A payment rate has been established for each APC. System similar to Diagnosis Related Group's (DRG) to be used for outpatients. Current scheme includes 346 APCs broken into categories of Medical, Diagnostic, Surgical, and Radiology and include Emergency Department and partial hospitalization services.

A freestanding facility, other than a physician office, where surgical, diagnostic, and therapeutic services are provided on an outpatient ambulatory basis.

A unit of the hospital, other than a nursing unit, which provides a medical services such as a diagnostic testing, therapeutic procedures, or dispense medical products, such as medications or medical/surgical supplies. Examples, laboratory, Medical imaging, physical therapy, pharmacy. Ancillary is used to describe diagnostic or therapeutic services, such as, laboratory, radiology, pharmacy, or physical therapy, performed by departments that do not have inpatient beds

The maximum dollar amount set by a Managed Care Organization (MCO) that limits the total amount the plan must pay for all health care services provided to a subscriber in a year. A deductible is the set amount, per benefit year or period, the third party payor designates as the patient/guarantor's responsibility. Usually the deductible must be paid before benefits will be paid by the payor. The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all health care services provided to a subscriber in a year.

An appeal is a special kind of complaint made when a beneficiary or provider disagrees with decisions about health care services typically related to payment issues. There is usually a special process used to appeal a payor decisions.

A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.

Written authorization from the policyholder to their insurance company to pay benefits directly to the care provider. Normally acquired at the time of admission or registration.

The physician who writes outpatient orders for tests, or supervises the patient's care during an inpatient stay.

Approval obtained from an insurance carrier for a service that represents an agreement for payment.

The form authorizing to release information from the medical records to doctors, hospitals, insurance, other agencies, etc.

The average number of inpatients maintained in the hospital for each day foe a specific period of time.

The average number of days of service rendered to each patient during a specific time period.

An accounts receivable that is regarded as uncollectible and is charged as a credit loss even though the patient has the ability to pay.

The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made.

Information technology term referring to grouping similar input items and then processing them together during a single machine run.

Assessment and treatment of mental and/or psychoactive substance abuse disorders.

Person designated to receive the proceeds of an insurance policy. The insured under a health insurance policy. Also referred to as eligibility, enrollee, or member. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract.

The process of confirming benefits for services. The process of verification of demographic, financial and insurance information that is obtained either through pre-registration or scheduling is second in importance only to the process of pre-certification. Truly, the two processes must go hand-in-hand to successfully defend the financial viability of the provider Contact should be made with the insurance company Benefits may vary significantly with the diagnosis. Together with pre-certification, verified coverage provides the hospital with essential information, in advance, to determine appropriate utilization review needs and alternative financial arrangements required.

The way that Medicare measures the use of hospital and skilled nursing facility services. A benefit period begins on the day of admission to hospital or skilled nursing facility and ends when the beneficiary has not received hospital or skilled nursing care for 60 days in a row. After the 60 days have elapsed a new benefit period begins. The beneficiary must pay