Abuse

The misuse of a person, substance, service, or financial matter such that harm is caused.

Actual Consent

The patient agrees to the treatment outlined; it can be either written or oral.

Approved Amount

The Medicare ceiling within a geographical area for a particular covered benefit.

Assignment

The provider agrees to accept the Medicare-approved amount as full payment for services provided under Parts A and B.

Average Daily Census

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

Average Daily Revenue

The average amount of revenue or charges generated

Average Days of

Revenue in AR

An estimate of the days required to turn over the AR under normal operating conditions.

Bad Debt

An uncollectible account resulting from the extension of credit.

Benefit Period

Begins the day a Medicare beneficiary is hospitalized and ends after the beneficiary has been out of the facility for 60 days in a row.

Birthday Rule

Determines COB when both parents have insurance for their children: the insurance policy of the parent whose birthday falls first in the calendar will be determined as the primary payer.

Capitation

Method of payment in which a provider is paid a fixed per capita amount for each person served, regardless of the actual number or nature of services provided to each person.

Census

Refers to the number of patients in the hospital at a particular point in time.

Chargemaster

A master pricing list that includes services, supplies, devices, and medication charges for inpatient or outpatient services.

Charity Care

Services provided where it is never expected to result in cash flow.

Clean Claim

A claim that does not require the FI to investigate or develop external to their Medicare operation; it passes all CWF edits, and is processed electronically.

Collection Control Points

Admission, pre-admission, in-house, at discharge, and after discharge.

Common Working File

A CMS file that contains Medicare patient eligibility and utilization data.

Condition Code

A UB-04 code that identifies the condition relating to the bill that may affect payer processing.

Continued Health Care Benefits

(CHCBP)

Provides health benefits to former service members and their families for 18-36 months after separation from Active Duty or loss of eligibility for military health care.

Defense Enrollment Eligibility Reporting System (DEERS)

A computerized database operated by the DOD and is used by Tricare contractors to confirm eligibility and obtain non-availability data.

Deposit

Estimated portion of the patient's bill not covered by insurance and paid or financed prior to or at the time of registration or discharge.

Diagnostic-Outpatient

The patient is referred by a physician to a diagnostic or therapeutic facility for diagnosis or treatment on an ambulatory basis.

Discharge of Debtor

Releases the guarantor/patient from financial responsibility of any and all account balances listed on a bankruptcy petition.

Dismissal

A court ruling whereby the bankruptcy is dismissed.

Dual Eligible

Individuals who are entitled to Medicare Part A and/or B and are also eligible for some form of Medicaid benefit.

Emergency-Outpatient

A patient registered to the emergency department for critical or sudden onset of illness requiring immediate diagnosis and treatment.

Expressed Consent

The patient agrees to the treatment outlined. It can be either written or oral.

False Claims Act

Imposes civil liability on any person or entity that submits a false or fraudulent claim for payment to the US government.

False Skip

Skips caused by clerical error at the time of registration.

Fraud

The intentional or illegal deception or misrepresentation made for the purpose of personal gain, or to harm or manipulate another person or organization.

Global Charges

The sum of the professional and technical components of a service when both are provided and billed by the same physician.

International Classification of Diseases, 9th Volume, Clinical Modification

The UB-04 code used to describe the diagnosis, trauma, and treatment rendered to the patient during the course of stay.

Implied Consent by Law

When a patient is unconscious and taken to the emergency room the law allows treating the patient.

Implied Consent in Fact

The patient implies consent to treatment by not objecting to it. This is consent by silence.

Incomplete Claim

Any claim with missing, required information.

Indigent

A patient that has no means of paying for the medical services or treatments and is not eligible for benefits under Medicaid or any other assistance program.

Informed Consent

The patient understands what he/she is being treated for and what procedures will be performed.

Inpatient

A registration ordered by the physician with the intent to provide ongoing services for a duration that usually exceeds 24 hours.

Insurance Coverage

The insurance payment liability on an insurance claim as stated in the terms of the policy between the patient and insurance company.

Insurance Claim

The statement of charges on patient accounts billed on standard billing forms to insurance companies for payment as stated in the terms of the policy between the patient and the insurance company.

Intentional Skip

A debtor who avoids paying their bills by changing their residency and failing to leave a forwarding address, or they purposely change their name or give intentional false information.

Invalid Claim

Any claim that contains complete and necessary information, however, the information is illogical or incorrect.

Judgment

A legally verified claim against a debtor.

Lien

A recorded claim against real or personal property, generally arising out of a debt.

Medical Necessity

Those services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.

Medigap

A health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits.

National Provider Identifier

(NPI)

A unique identification number for covered health care providers.

Non Availability Statement

(NAS)

Certifies that a MTF is not available to provide inpatient services; it is required before any non-emergent inpatient services may be provided to a Tricare Extra or Standard eligible beneficiary by a non-MTF.

Non-Participating Provider

A provider that has not contracted with an insurance carrier or managed care plan to provide health services to plan members.

Occurrence Code

The UB-04 code that identifies the specific data defining a significant event relating to the bill that may affect payment processing.

Outpatient

An individual receiving hospital based or coordinated medical service for which the hospital is responsible. The outpatient does not require overnight service, with the exception of observation.

Percentage of Occupancy

The ration of actual patient days to the maximum patient days as determined by bed capacity during any given period of time.

Per Diem

Reimbursement based on a set rate per day in the hospital regardless of any actual charges or costs incurred.

PreAdmission Testing

The diagnostic medical testing of patients in advance of surgical or invasive procedures to determine hospitalization and/or surgical suitability.

Pre-certification

Confirming eligibility and collecting information prior to inpatient admissions and selected ambulatory procedures and services. Issuance of a prior authorization by an insurance company review organization approving the medical necessity of the hospitalization.

Pre Registration

The process and confirmation of patient demographic and financial information at least 24 hours in advance.

Recurring/Series

Type of outpatient account established to capture ongoing charges for a patient for a specified period of time. Eg. rehab, chemo, dialysis, etc.

Registration

Obtaining and recording demographic, financial, and personal information for the use by the provider to conduct business, as well as maintain legal medical records according to all applicable state and federal statutes.

Return as Unprocessable

The term used by Medicare for notifying you that your claim cannot be processed, and that it must be corrected and/or resubmitted.

Revenue Code

The UB-04 code that identifies a specific accommodation, ancillary service, or billing calculation.

Same Day Surgery

The patient receives surgical services as an outpatient.

Skip

A debtor who cannot be located by the creditor.

Statute of Limitations

The amount of time in which a claim must be collected before it is deemed paid or satisfied.

Third Party

Insurance coverage that pays a portion (or all) of total charges on a patient account.

Timely Filing

The shortest time period between provider's discharge and claim completion mailed or carried to the patient's insurance company.

Tort Liability

A liability for an injury or wrongdoing done by one person to another resulting from a breach of legal duty.

Un-intentional Skip

A patient who moves or changes their residency, but fails to notify creditors. A forwarding address is normally on file.

Value Code

The UB-04 code used to identify values of monetary nature.