CHAM Newest Exam with precise detailed solutions ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Accepting Assignment ||\\//||
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.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Access
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.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Account Number ||\\//||
A number assigned to each account. This number is used to identify the account and all
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
charges and payments received. ||\\//|| ||\\//|| ||\\//||
Acute Care ||\\//||
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. ||\\//||
Acute Impatient Care ||\\//|| ||\\//||
A level of health-care delivered to patients experiencing acute illness or trauma. Acute care
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is generally short-term (< 30 days).
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Add-Ons
Patients who are scheduled for services less than 24 hours in advance of the actual service
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
time.
Adjustor
Insurance company representative. ||\\//|| ||\\//||
Administrative Costs ||\\//||
Costs associated with creating and submitting a bill for services, which could include:
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
registration, utilization review, coding, billing and collection expenses ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
,Admission Authorization ||\\//||
The process of third-party payer notification of urgent/emergent inpatient admission within
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
specified time as determined by payers (usually 24-48 hours or next business day).
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admission Date ||\\//||
The first date the patient entered the hospital for a specific visit
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admitting Diagnosis ||\\//||
Word, phrase or 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. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admitting Physician ||\\//||
The physician who writes the order for the patient to be admitted to the hospital. This
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
physician must have admitting privileges at the facility providing the healthcare services. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Advance Beneficiary Notice (ABN) ||\\//|| ||\\//|| ||\\//||
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 advance beneficiary notice (ABN) allows the beneficiary to make an informed decision
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
prior to services regarding whether or not they wish to receive services. ABNs are not
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
routinely given to emergency department patients. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Advance Directive ||\\//||
is a written instruction relating to the provision of healthcare when a patient is
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
incapacitated. It could include appointing someone to make medical decisions, a statement ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
expressing the patient's wishes about anatomical gifts (i.e. organ donation) and general ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
statements about whether or not life-sustaining treatments should be withheld or ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
withdrawn.
Adverse Selection ||\\//||
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 ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Alias
a name by which the patient is also "known as," or formerly known as
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
,All Patient Diagnosis Related Groups Assignment of Benefits (APDRG)
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A prospective hospital claims reimbursement system currently utilized by the federal
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
government Medicaid program and the states of New York and New Jersey. They were ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
designed to describe the complete cross section of patients seen in acute care hospitals. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Approximately 639 ___ are defined according to the principal diagnosis, secondary ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
diagnoses, procedures, age, birth weight, sex and discharge status. Each category has an ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
established fixed reimbursement rate based on average cost of treatment within a ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
geographic area. Theywere 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 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.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Alphanumeric
Letters, 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. ||\\//|| ||\\//|| ||\\//||
Ambulatory Care Patient ||\\//|| ||\\//||
Patient receives medical or surgical care in an 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 healthcare ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
services provided on an outpatient basis. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ambulatory Payment Classification (APC) ||\\//|| ||\\//|| ||\\//||
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 of CPT codes based ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
on clinical and resource similarity and establishes payment rates for each APC grouping.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
The 650 + 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. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ambulatory Surgical Center ||\\//|| ||\\//||
A freestanding facility, other than a physician's office, where surgical, diagnostic and
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
therapeutic services are provided on an outpatient ambulatory basis. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ancillary Services ||\\//||
A unit of the hospital, other than a nursing unit, that provides medical services such as
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
diagnostic testing and therapeutic procedures, or dispenses medical products, such as ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
medications or medical/surgical supplies. Examples: Laboratory, Medical Imaging, Physical ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Therapy and 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.
||\\//|| ||\\//|| ||\\//|| ||\\//||
Annual Maximum Benefit Amount Deductible ||\\//|| ||\\//|| ||\\//|| ||\\//||
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, that the thirdparty payer
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
designates as the patient/guarantor's responsibility. Usually the deductible must be paid ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
before benefits will be paid by the payer. 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. ||\\//|| ||\\//|| ||\\//||
Appeal
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 payer decisions. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Appropriate Care ||\\//||
A diagnostic or treatment measure whose expected health benefits exceed its expected
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
health risks by a wide enough margin to justify the measure. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Assignment of Benefit ||\\//|| ||\\//||
Written authorization from the policyholder for their insurance company to pay benefits ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
directly to the care provider. Normally acquired at the time of admission or registration. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Attending Physician ||\\//||
Accepting Assignment ||\\//||
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.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Access
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.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Account Number ||\\//||
A number assigned to each account. This number is used to identify the account and all
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
charges and payments received. ||\\//|| ||\\//|| ||\\//||
Acute Care ||\\//||
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. ||\\//||
Acute Impatient Care ||\\//|| ||\\//||
A level of health-care delivered to patients experiencing acute illness or trauma. Acute care
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is generally short-term (< 30 days).
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Add-Ons
Patients who are scheduled for services less than 24 hours in advance of the actual service
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
time.
Adjustor
Insurance company representative. ||\\//|| ||\\//||
Administrative Costs ||\\//||
Costs associated with creating and submitting a bill for services, which could include:
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
registration, utilization review, coding, billing and collection expenses ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
,Admission Authorization ||\\//||
The process of third-party payer notification of urgent/emergent inpatient admission within
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
specified time as determined by payers (usually 24-48 hours or next business day).
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admission Date ||\\//||
The first date the patient entered the hospital for a specific visit
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admitting Diagnosis ||\\//||
Word, phrase or 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. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Admitting Physician ||\\//||
The physician who writes the order for the patient to be admitted to the hospital. This
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
physician must have admitting privileges at the facility providing the healthcare services. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Advance Beneficiary Notice (ABN) ||\\//|| ||\\//|| ||\\//||
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 advance beneficiary notice (ABN) allows the beneficiary to make an informed decision
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prior to services regarding whether or not they wish to receive services. ABNs are not
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routinely given to emergency department patients. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Advance Directive ||\\//||
is a written instruction relating to the provision of healthcare when a patient is
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incapacitated. It could include appointing someone to make medical decisions, a statement ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
expressing the patient's wishes about anatomical gifts (i.e. organ donation) and general ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
statements about whether or not life-sustaining treatments should be withheld or ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
withdrawn.
Adverse Selection ||\\//||
Among applicants for a given group or individual program, the tendency for those with an
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impaired health status, or who are prone to higher than average utilization of benefits to be ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
enrolled in disproportionate numbers and lower deductible plans ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Alias
a name by which the patient is also "known as," or formerly known as
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,All Patient Diagnosis Related Groups Assignment of Benefits (APDRG)
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A prospective hospital claims reimbursement system currently utilized by the federal
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government Medicaid program and the states of New York and New Jersey. They were ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
designed to describe the complete cross section of patients seen in acute care hospitals. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Approximately 639 ___ are defined according to the principal diagnosis, secondary ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
diagnoses, procedures, age, birth weight, sex and discharge status. Each category has an ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
established fixed reimbursement rate based on average cost of treatment within a ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
geographic area. Theywere developed to quantify the difference in demographic groups and ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
clinical risk factors for patients treated in hospitals. This proprietary grouping system's (i.e.
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3M) purpose is to obtain fair and accurate statistical comparisons between disparate
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populations and groups. Unlike the Diagnosis Related Group (DRG) reimbursement system, ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
which is intended to capture resource utilization intensity, the system captures and relates
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the Severity of Illness and Risk of Mortality factors present as a result of a patient's disease
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and disorders and the interaction of those disorders. A form is signed by the Patient giving
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the healthcare provider authority to bill his/her insurance plan and receive payment. The
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form is generally presented and signed at the time of registration.
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Alphanumeric
Letters, 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
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field or in coding. ||\\//|| ||\\//|| ||\\//||
Ambulatory Care Patient ||\\//|| ||\\//||
Patient receives medical or surgical care in an outpatient setting that involves a broader, less
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specialized range of care. Ambulatory patients are generally able to walk and are not
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confined to a bed. In a hospital setting, ambulatory care generally refers to healthcare ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
services provided on an outpatient basis. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ambulatory Payment Classification (APC) ||\\//|| ||\\//|| ||\\//||
A system of averaging and bundling using Current Procedural Terminology (CPT)
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procedure codes, Healthcare Common Procedure Coding System (HCPCS) Level II, and ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
revenue codes submitted for payment. The APC system utilizes groups of CPT codes based ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
on clinical and resource similarity and establishes payment rates for each APC grouping.
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The 650 + APCs are divided by significant procedures, medical services, ancillary services
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and partial hospitalization services. The APCs are similar clinically, by resources used and
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cost. A payment rate has been established for each APC. System similar to Diagnosis
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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. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ambulatory Surgical Center ||\\//|| ||\\//||
A freestanding facility, other than a physician's office, where surgical, diagnostic and
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therapeutic services are provided on an outpatient ambulatory basis. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Ancillary Services ||\\//||
A unit of the hospital, other than a nursing unit, that provides medical services such as
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diagnostic testing and therapeutic procedures, or dispenses medical products, such as ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
medications or medical/surgical supplies. Examples: Laboratory, Medical Imaging, Physical ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Therapy and Pharmacy. Ancillary is used to describe diagnostic or therapeutic services, ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
such as laboratory, radiology, pharmacy or physical therapy, performed by departments that
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do not have inpatient beds.
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Annual Maximum Benefit Amount Deductible ||\\//|| ||\\//|| ||\\//|| ||\\//||
The maximum dollar amount set by a Managed Care Organization (MCO) that limits the
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total amount the plan must pay for all health-care services provided to a subscriber in a
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year. A deductible is the set amount, per benefit year or period, that the thirdparty payer
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designates as the patient/guarantor's responsibility. Usually the deductible must be paid ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
before benefits will be paid by the payer. 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
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subscriber in a year. ||\\//|| ||\\//|| ||\\//||
Appeal
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 payer decisions. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Appropriate Care ||\\//||
A diagnostic or treatment measure whose expected health benefits exceed its expected
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
health risks by a wide enough margin to justify the measure. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Assignment of Benefit ||\\//|| ||\\//||
Written authorization from the policyholder for their insurance company to pay benefits ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
directly to the care provider. Normally acquired at the time of admission or registration. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Attending Physician ||\\//||
