|
Encounter Data
Detailed data about individual services provided by a capitated managed
care entity. The level of detail about each service reported is similar to that
of a standard claim form. Encounter data are also sometimes referred to as "shadow
claims".
CPT - Current Procedural Terminology
Physicians' Current Procedural Terminology (CPT®), Fourth Edition,
is a listing of descriptive terms and identifying codes for reporting medical services
and procedures. The purpose of CPT is to provide a uniform language that accurately
describes medical, surgical, and diagnostic services, and thereby serves as an effective
means for reliable nationwide communication among physicians, patients, and third
parties.
CPT descriptive terms and identifying codes currently serve a wide variety of important
functions. This system of terminology is the most widely accepted medical nomenclature
used to report medical procedures and services under public and private health insurance
programs. CPT is also used for administrative management purposes such as claims
processing and developing guidelines for medical care review.
The uniform language is likewise applicable to medical education and research by
providing a useful basis for local, regional, and national utilization comparisons.
The CPT Editorial Panel is responsible for maintaining the CPT nomenclature. This
panel is authorized to revise, update, or modify the CPT codes.
HIPAA and CPT
The Administrative Simplification Section of the Health Insurance Portability
and Accountability Act (HIPAA) requires the Department of Health and Human Services
to name national standards for electronic transaction of health care information.
This includes transactions and code sets, national provider identifier, national
employer identifier, security, and privacy. The FinalRule for transactions and code
sets was issued on August 17, 2000. The rule names CPT (including codes and modifiers)
and HCPCS as the procedure code set for:
Physician services
Physical and occupational therapy services
Radiological procedures
Clinical laboratory tests
Other medical diagnostic procedures
Hearing and vision services
Transportation services including ambulance
The Final rule also named ICD-9-CM volume 1 and 2 as the code set for diagnosis
codes, ICD-9-CMvolume 3 for inpatient hospital services, Current Dental Terminology
(CDT) for dental services, and National Drug Codes (NDC) for drugs.
All health care plans and providers who transmit information electronically must
use established national standards. In addition, the Final Rule called for the elimination
of local codes and for the transition to national standard code sets. This means
that HCPCS level 3 codes and other local codes cannot be used.
Medicare
The federal health insurance program for: people 65 years of age or older, certain
younger people with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure with dialysis or a transplant, sometimes called ESRD).
Medical bills are paid from trust funds, which those covered, have paid into. It
serves people over 65 primarily, whatever their income; and serves younger disabled
people and dialysis patients. Patients pay part of costs through deductibles for
hospital and other costs. Small monthly premiums are required for non-hospital coverage.
Medicare is a federal program. It is basically the same everywhere in the United
States and is run by the Health Care Financing Administration, an agency of the
federal government.
Medicaid
An assistance program. Medical bills are paid from federal, state and local tax
funds. It serves low-income people of every age. Patients usually pay no part of
costs for covered medical expenses. A small co-payment is sometimes required. Medicaid
is a federal-state program. It varies from state to state. It is run by state and
local governments within federal guidelines.
Medicare Carrier
A private company that contracts with Medicare to pay Part B bills.
Medicare Contractor
A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier
(professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)
Medicare Coverage
Made up of two parts:
Hospital Insurance (Part A) and
Medical Insurance (Part B)
(See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).
Medicare Part-A (Hospital Insurance)
Hospital insurance that pays for inpatient hospital stays, specialized care in a
skilled nursing facility, hospital care and some home health care.
(See Hospital Insurance (Part A)
Medicare Part-B (MEdical Insurance)
Medical insurance that helps pay for:
Doctor's services Outpatient hospital care, and
Other medical services that are not covered by Part A. (See Medical Insurance (Part
B). )
Medicare Part-B Carrier
A Medicare contractor that administers the Medicare Part B (Professional) benefits
for a given region.
Medicare Part-A FIscal Intermediary
A Medicare contractor that administers the Medicare Part A (institutional)
benefits for a given region
Health Care Provider
A person who is trained and licensed to give health care. Also, a place licensed
to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some
assisted living facilities, and certain kinds of home health agencies are examples
of health care providers.
Medicare Part-B Carrier
A Medicare contractor that administers the Medicare Part B (Professional) benefits
for a given region.
Health Insurance Claims Number
The number assigned by the Social Security Administration to an individual
identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary's
insurance card and is used in processing Medicare claims for that beneficiary.
Health Insurance Portability & Accountability Act (HIPAA)
A law passed in 1996, which is also sometimes called the "Kassebaum-Kennedy" law.
This law expands your health care coverage if you have lost your job, or if you
move from one job to another, HIPAA protects you and your family if you have: pre-existing
medical conditions, and/or problems getting health coverage, and you think it is
based on past or present health. HIPAA also limits how companies can use your pre-existing
medical conditions to keep you from getting health insurance coverage; usually gives
you credit for health coverage you have had in the past; may give you special help
with group health coverage when you lose coverage or have a new dependent; and generally,
guarantees your right to renew your health coverage. HIPAA does not replace the
states' roles as primary regulators of insurance
Healthcare Insurance Portability & Accountability Act Of 1996
A regulation to guarantee patients new rights and protections against the
misuse or disclosure of their health records.
Healthcare Insurance Portability & Accountability Act Of 1996
A Federal law that allows persons to qualify immediately for comparable health insurance
coverage when they change their employment relationships. Title II, Subtitle F,
of HIPAA gives HHS the authority to mandate the use of standards for the electronic
exchange of health care data; to specify what medical and administrative code sets
should be used within those standards;
To require the use of national identification systems for health care patients,
providers, payers (or plans), and employers (or sponsors); and to specify the types
of measures required to protect the security and privacy of personally identifiable
health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy
Bill, K2, or Public Law 104-191.
Health Insuring Organization
An entity that provides for or arranges for the provision of care and contracts
on a prepaid capitated risk basis to provide a comprehensive set of services.
Health Level Seven
An ANSI-accredited group that defines standards for the cross-platform
exchange of information within a health care organization. HL7 is responsible for
specifying the Level Seven OSI standards for the health industry.
Health Level Seven (HL7) is an American National Standards Institute (ANSI) accredited
standards organization and a standard. As an organization, HL7's mission is to provide
standards for:
Exchange
Management and Integration of data that support clinical patient care
The standard defines the protocol for exchanging clinical data between diverse healthcare
information systems.
HL7 version 2.X commonly specifies the majority of the interface information without
difficulties, albeit with a few limitations.
The current version, HL7 2.4, has established itself as a nearly universal standard
for clinical and administrative data. Version 3.0, currently in draft, will further
extend the functionality of health data exchange.
Health Plan
An entity that assumes the risk of paying for medical treatments, i.e.
uninsured patient, self-insured employer, payer, or HMO.
Healthcare Common Procedural COding System
A medical code set that identifies health care procedures, equipment, and
supplies for claim submission purposes. It has been selected for use in the HIPAA
transactions.
HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS
Level II contains alphanumeric codes used to identify various items and services
that are not included in the CPT medical code set. These are maintained by HCFA,
the BCBSA, and the HIPAA.
HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state
agencies to identify additional items and services not included in levels I or II.
These are usually called "local codes", and must have "W", "X", "Y", or "Z" in the
first position. HCPCS Procedure Modifier Codes can be used with all three levels,
with the WA - ZY range used for locally assigned procedure modifiers.
Hospital Coinsurance
For the 61st through 90th day of hospitalization in a benefit period, a
daily amount for which the beneficiary is responsible, equal to one-fourth of the
inpatient hospital deductible; for lifetime reserve days, a daily amount for which
the beneficiary is responsible, equal to one-half of the inpatient hospital deductible
(See "Lifetime reserve days") .
Hospital Insurance
The Medicare program that covers specified inpatient hospital services; post hospital
skilled nursing care, home health services, and hospice care for aged and disabled
individuals who meet the eligibility requirements. Also known as Medicare Part A.
Hospital Insurance (Part A)
The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing
facility, hospice care and some home health care.
Healthcare Financing Administration(HCFA)
Former name of the government agency now called the Centers for Medicare & Medicaid
Services.
HCFA-1450
HCFA's name for the institutional uniform claim form, or UB-92.
HCFA-1500
HCFA's name for the professional uniform claim form. Also known as the
UCF-1500.
HMO (Health Maintenance Organization)
A health plan that is also involved in how health care is delivered. Managed
care refers to health plans coordinating health care with the patient and the providers
that participate in the health plan. HMOs are the most common type of managed care.
A Medicare HMO
An HMO that has contracted with the federal government under the Medicare+
Choice program to provide health benefits to persons eligible for Medicare that
choose to enroll in the HMO, instead of receiving their benefits and care through
the traditional fee for service Medicare program
Deductible
A predetermined amount of money that a person commits to pay before the
Insurance Company is responsible for any benefit payments. This is done so that
people will make sure that any problem that an insured might have really needs medical
assistance. It is a way for Insurance Companies to keep premium costs down.
Coinsurance
Coinsurance is the portion of medical costs that are shared by both the
Insured (the patient) and the Insurer. For example, if you have an 80% to $5,000
coinsurance; The Insurer is responsible for 80% of the next $5,000 in covered medical
expenses.
The Insured is responsible for 20% of that same $5,000 in covered medical expenses.
So in the above mentioned policy with $1,000 deductible and 80% co-insurance to
$5,000;
If a covered event occurred that had a total cost of $10,000, the insured would
be responsible for the first $1,000 (deductible) Of the next $5,000 in covered expenses,
the insured would pay another $1,000 (coinsurance).
After deductibles and coinsurance are satisfied, Insurance Companies pay 100% of
all other covered expenses. So for this example the Insured would pay $2,000 and
the Insurer would pay $8,000.
Claim Scrubbing
It is a method designed to detect claim coding and compliance issues before submission
for reimbursement. Identifying claim errors efficiently can dramatically accelerate
practice's reimbursement cycle and detect system inefficiencies.
Electronic Claim Processing
This is the processing medical claim electronically which had many benefits
like, receives priority processing, Electronic medical claims submitted go directly
to the payer's processing unit, ensuring faster turnaround. Paper claims are processed
only after manual sorting and batching.
Many practices are turning to electronic claims processing because of the vast time
and money savings that result. Processing insurance claims electronically improves
cash flow, reduces the expense of claims processing and streamlines internal processes
allowing a practice to focus on patient care.
The reduction in insurance reimbursement time results in a significant increase
in cash available for the needs of a growing practice. In addition, by reducing
the internal expenses associated with processing paper claims, reduced labor, office
supplies and postage all contribute to the bottom of the practice when submitting
claims electronically.
Super bill
A modified claim form that lists specific and/or specialty medical services
provided by a physician. It cannot be used in place of the standard AMA form.
Capitation
Specified amount paid periodically to health provider for a group of specified health
services, regardless of quantity rendered. Amounts are determined by assessing a
payment "per covered life" or per member.
The method of payment in which the provider is paid a fixed amount for each person
served no matter what the actual number or nature of services delivered.
The cost of providing an individual with a specific set of services over a set period
of time, usually a month or a year. Providers are not reimbursed for services that
exceed the allotted amount. The rate may be fixed for all members or it can be adjusted
for the age and gender of the member, based on actuarial projections of medical
utilization.
Assignment of Benefits
An arrangement by which a patient requests that their health benefit payments be
made directly to a designated person or facility, such as a physician or hospital.
|
