Administrative Assisting terms

50 glossary entries from the Administrative Assisting topic of the CCMA test plan. Try free Administrative Assisting practice questions.

• ABNAdvance Beneficiary Notice of Non-coverage: a Medicare form telling the patient, before the service, that Medicare may…
• allowed amountThe maximum a plan will pay for a covered service; also called the eligible expense or negotiated rate.
• appealA request that the health plan review a decision denying a benefit or payment.
• balance billingA provider billing the patient for the difference between its charge and the plan's allowed amount; network providers…
• birthday ruleA coordination-of-benefits rule: a child covered by both parents uses first the plan of the parent whose birthday…
• charting by exceptionDocumenting only findings that differ from established normal standards.
• claimA request to a health plan for payment for services provided.
• CMS-1500The standard paper claim form for professional (physician and supplier) services; the electronic version is the 837P.
• COBCoordination of benefits: rules that decide which insurer pays first when a patient has more than one plan.
• coinsuranceThe patient's share of a covered service, figured as a percentage of the allowed amount.
• copaymentA fixed dollar amount the patient pays for a covered service, usually at the visit.
• CPOEComputerized provider order entry: the provider enters orders electronically instead of on paper.
• CPTCurrent Procedural Terminology: the AMA code set for medical services and procedures.
• deductibleThe amount the patient owes for covered services each coverage period before the plan starts to pay.
• DMEDurable medical equipment: reusable equipment ordered for home use, such as walkers, wheelchairs or oxygen equipment.
• double-bookingScheduling two patients in the same time slot with the same provider.
• E/MEvaluation and management: the category of codes for office, outpatient, hospital and other patient visits.
• EFTElectronic funds transfer: a health plan's payment sent electronically to the provider's bank.
• EHRElectronic health record: a digital record of a patient's health information that can be shared across providers.
• EMRElectronic medical record: a digital chart kept by one practice.
• EOBExplanation of benefits: a health plan's statement explaining how a claim was processed and paid; the primary payer's…
• ERAElectronic remittance advice: the electronic explanation of a claim payment sent by the health plan to the provider.
• grievanceA complaint made to a health insurer or plan.
• HCPCSHealthcare Common Procedure Coding System; Level II codes cover supplies, equipment and services not in CPT.
• HMOHealth maintenance organization: a managed care plan that usually pays only for in-network care and uses a primary…
• ICD-10-CMInternational Classification of Diseases, 10th Revision, Clinical Modification: the code set for diagnoses.
• MCOManaged care organization: an entity that contracts to provide or arrange covered health services, often for Medicaid.
• MedicaidJoint federal and state health insurance for many people with low income; each state sets its own rules.
• medically necessaryServices or supplies needed to prevent, diagnose or treat an illness, injury or condition and that meet accepted…
• MedicareThe federal health insurance program for people 65 or older and some younger people with disabilities or permanent…
• Medicare AdvantageMedicare Part C: an option to receive all Part A and B care through a provider organization, such as an HMO.
• Medicare Part AMedicare hospital insurance.
• Medicare Part BMedicare medical insurance that helps pay for medical services Part A does not cover.
• Medicare Part DMedicare prescription drug coverage.
• MSPMedicare Secondary Payer: rules that make another insurer pay before Medicare in certain situations.
• networkThe providers and facilities a health plan has contracted with to provide care.
• no-showA patient who misses a scheduled appointment without canceling.
• NPINational Provider Identifier: the unique 10-digit number HIPAA requires for health care providers on claims.
• out-of-pocket limitThe most a patient must pay for covered services in a plan year; after that the plan pays 100 percent.
• POSPlace of service: a two-digit claim code showing where care was given. In insurance, also a point-of-service plan.
• PPOPreferred provider organization: a managed care plan that pays more for in-network care but still pays part of…
• preauthorizationA plan's advance decision that a service, drug or equipment is medically necessary; also called prior authorization.
• premiumThe amount paid, often monthly, to buy and keep health insurance.
• primary insuranceThe plan that pays a claim first when a patient has more than one; the secondary plan then considers the remaining…
• problem-oriented medical recordA record organized around the patient's problems, often with SOAP notes.
• SOAP noteA documentation format: Subjective, Objective, Assessment, Plan.
• source-oriented recordA medical record organized into sections by the source (discipline) that provided the information.
• UCRUsual, customary and reasonable: the amount paid for a service in an area based on what providers there usually charge.
• unbundlingBilling the parts of a service separately instead of using the single code that covers the whole service.
• upcodingBilling a higher level of service than was provided or documented; a form of fraud.