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8 Cards in this Set
- Front
- Back
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health insurance claim |
documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided |
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preauthorization |
prior approval for treatment by specialists and documentation of post-treatment reports |
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hold harmless clause |
patient is not responsible for paying what the insurance plan denies-but must be listed as a part of the insurance policy |
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health care provider |
physician or other health care practitioner |
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CMS (Centers for Medicare and Medicaid Services) |
administrative agency within the federal Department of Health and Human Services (DHHS) |
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Health insurance specialists, aka Reimbursement specialists |
review health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider |
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Claims examiner |
employed by third-party payer, reviews health-related claims to determine whether the charges are reasonable and medically necessary |
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medical necessity |
involves linking every procedure or service code reported on the claim to a condition code (disease, injury, sign, symptom, or other reason for encounter) that justifies the need to perform that procedure or service |
