Page | 1
NAHAM Glossary Questions and Verified Answers
Accepting Assignment
Ans: 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
Ans: 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
Ans: A number assigned to each account. This number is used to identify
the account and all charges and payments received.
Acute Care
Ans: 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 Inpatient Care
Ans: A level of health-care delivered to patients experiencing acute illness or
trauma. Acute Care is generally short term (<30 days).
Add-Ons
Ans: Patients who are scheduled for services less than 24 hours in advance
of the actual service time.
Adjustor
Ans: Insurance company representative.
Administrative Costs
, Page | 2
Ans: Costs associated with creating and submitting a bill for services, which
could include: registration, utilization review, coding, billing, and collection
expenses.
Admission Authorization
Ans: The process of third party payor notification of urgent/emergent
inpatient admission within specified time as determined by payors (usually
24-48 hours or next business day).
Admission Date
Ans: The first date the patient entered the hospital for a specific visit.
Admitting Diagnosis
Ans: Word, phrase, of International Classification of Disease (ICD9) code
used by the admitting physician to identify a condition or disease from
which the patient suffers and for which the patient needs or seeks medical
care.
Admitting Physician
Ans: 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)
Ans: 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 pay not pay for them. The 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
Ans: An 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
, Page | 3
Ans: 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.
All Patient Diagnosis Related Groups Assignment of Benefits (APDRG)
Ans: 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 diagnosis,
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. APRDRGs 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 related the Severity of Illness
and Risk of Mortality factors present as a result of a patient's disease and
disorders and the interactions of those disorders. A form is signed by the
Patient giving the healthcare provider authority to bill his/her insurance
plan and receive payment. This form is generally presented and signed at
the time of registration.
Ambulatory Care Patient
Ans: Patients 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)
NAHAM Glossary Questions and Verified Answers
Accepting Assignment
Ans: 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
Ans: 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
Ans: A number assigned to each account. This number is used to identify
the account and all charges and payments received.
Acute Care
Ans: 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 Inpatient Care
Ans: A level of health-care delivered to patients experiencing acute illness or
trauma. Acute Care is generally short term (<30 days).
Add-Ons
Ans: Patients who are scheduled for services less than 24 hours in advance
of the actual service time.
Adjustor
Ans: Insurance company representative.
Administrative Costs
, Page | 2
Ans: Costs associated with creating and submitting a bill for services, which
could include: registration, utilization review, coding, billing, and collection
expenses.
Admission Authorization
Ans: The process of third party payor notification of urgent/emergent
inpatient admission within specified time as determined by payors (usually
24-48 hours or next business day).
Admission Date
Ans: The first date the patient entered the hospital for a specific visit.
Admitting Diagnosis
Ans: Word, phrase, of International Classification of Disease (ICD9) code
used by the admitting physician to identify a condition or disease from
which the patient suffers and for which the patient needs or seeks medical
care.
Admitting Physician
Ans: 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)
Ans: 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 pay not pay for them. The 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
Ans: An 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
, Page | 3
Ans: 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.
All Patient Diagnosis Related Groups Assignment of Benefits (APDRG)
Ans: 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 diagnosis,
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. APRDRGs 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 related the Severity of Illness
and Risk of Mortality factors present as a result of a patient's disease and
disorders and the interactions of those disorders. A form is signed by the
Patient giving the healthcare provider authority to bill his/her insurance
plan and receive payment. This form is generally presented and signed at
the time of registration.
Ambulatory Care Patient
Ans: Patients 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)
