Encounter Data
Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims".

CPT - Current Procedural Terminology
Physicians' Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.

CPT descriptive terms and identifying codes currently serve a wide variety of important functions. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

The uniform language is likewise applicable to medical education and research by providing a useful basis for local, regional, and national utilization comparisons.
The CPT Editorial Panel is responsible for maintaining the CPT nomenclature. This panel is authorized to revise, update, or modify the CPT codes.

HIPAA and CPT
The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) requires the Department of Health and Human Services to name national standards for electronic transaction of health care information. This includes transactions and code sets, national provider identifier, national employer identifier, security, and privacy. The FinalRule for transactions and code sets was issued on August 17, 2000. The rule names CPT (including codes and modifiers) and HCPCS as the procedure code set for:

Physician services
Physical and occupational therapy services
Radiological procedures
Clinical laboratory tests
Other medical diagnostic procedures
Hearing and vision services
Transportation services including ambulance

The Final rule also named ICD-9-CM volume 1 and 2 as the code set for diagnosis codes, ICD-9-CMvolume 3 for inpatient hospital services, Current Dental Terminology (CDT) for dental services, and National Drug Codes (NDC) for drugs.
All health care plans and providers who transmit information electronically must use established national standards. In addition, the Final Rule called for the elimination of local codes and for the transition to national standard code sets. This means that HCPCS level 3 codes and other local codes cannot be used.

Medicare
The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD).
Medical bills are paid from trust funds, which those covered, have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.

Medicaid
An assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines.

Medicare Carrier
A private company that contracts with Medicare to pay Part B bills.

Medicare Contractor
A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

Medicare Coverage
Made up of two parts:
Hospital Insurance (Part A) and
Medical Insurance (Part B)
(See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).

Medicare Part-A (Hospital Insurance)
Hospital insurance that pays for inpatient hospital stays, specialized care in a skilled nursing facility, hospital care and some home health care.
(See Hospital Insurance (Part A)

Medicare Part-B (MEdical Insurance)
Medical insurance that helps pay for:
Doctor's services Outpatient hospital care, and
Other medical services that are not covered by Part A. (See Medical Insurance (Part B). )

Medicare Part-B Carrier
A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

Medicare Part-A FIscal Intermediary
A Medicare contractor that administers the Medicare Part A (institutional) benefits for a given region

Health Care Provider
A person who is trained and licensed to give health care. Also, a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers.

Medicare Part-B Carrier
A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

Health Insurance Claims Number
The number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary's insurance card and is used in processing Medicare claims for that beneficiary.

Health Insurance Portability & Accountability Act (HIPAA)
A law passed in 1996, which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage; usually gives you credit for health coverage you have had in the past; may give you special help with group health coverage when you lose coverage or have a new dependent; and generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance

Healthcare Insurance Portability & Accountability Act Of 1996
A regulation to guarantee patients new rights and protections against the misuse or disclosure of their health records.

Healthcare Insurance Portability & Accountability Act Of 1996
A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards;

To require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.

Health Insuring Organization
An entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

Health Level Seven
An ANSI-accredited group that defines standards for the cross-platform exchange of information within a health care organization. HL7 is responsible for specifying the Level Seven OSI standards for the health industry.
Health Level Seven (HL7) is an American National Standards Institute (ANSI) accredited standards organization and a standard. As an organization, HL7's mission is to provide standards for:
Exchange
Management and Integration of data that support clinical patient care

The standard defines the protocol for exchanging clinical data between diverse healthcare information systems.
HL7 version 2.X commonly specifies the majority of the interface information without difficulties, albeit with a few limitations.
The current version, HL7 2.4, has established itself as a nearly universal standard for clinical and administrative data. Version 3.0, currently in draft, will further extend the functionality of health data exchange.

Health Plan
An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.

Healthcare Common Procedural COding System
A medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions.
HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIPAA.
HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W", "X", "Y", or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA - ZY range used for locally assigned procedure modifiers.

Hospital Coinsurance
For the 61st through 90th day of hospitalization in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-fourth of the inpatient hospital deductible; for lifetime reserve days, a daily amount for which the beneficiary is responsible, equal to one-half of the inpatient hospital deductible (See "Lifetime reserve days") .

Hospital Insurance
The Medicare program that covers specified inpatient hospital services; post hospital skilled nursing care, home health services, and hospice care for aged and disabled individuals who meet the eligibility requirements. Also known as Medicare Part A.

Hospital Insurance (Part A)
The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

Healthcare Financing Administration(HCFA)
Former name of the government agency now called the Centers for Medicare & Medicaid Services.

HCFA-1450
HCFA's name for the institutional uniform claim form, or UB-92.

HCFA-1500
HCFA's name for the professional uniform claim form. Also known as the UCF-1500.

HMO (Health Maintenance Organization)
A health plan that is also involved in how health care is delivered. Managed care refers to health plans coordinating health care with the patient and the providers that participate in the health plan. HMOs are the most common type of managed care.

A Medicare HMO
An HMO that has contracted with the federal government under the Medicare+ Choice program to provide health benefits to persons eligible for Medicare that choose to enroll in the HMO, instead of receiving their benefits and care through the traditional fee for service Medicare program

Deductible
A predetermined amount of money that a person commits to pay before the Insurance Company is responsible for any benefit payments. This is done so that people will make sure that any problem that an insured might have really needs medical assistance. It is a way for Insurance Companies to keep premium costs down.

Coinsurance
Coinsurance is the portion of medical costs that are shared by both the Insured (the patient) and the Insurer. For example, if you have an 80% to $5,000 coinsurance; The Insurer is responsible for 80% of the next $5,000 in covered medical expenses.
The Insured is responsible for 20% of that same $5,000 in covered medical expenses.
So in the above mentioned policy with $1,000 deductible and 80% co-insurance to $5,000;
If a covered event occurred that had a total cost of $10,000, the insured would be responsible for the first $1,000 (deductible) Of the next $5,000 in covered expenses, the insured would pay another $1,000 (coinsurance).

After deductibles and coinsurance are satisfied, Insurance Companies pay 100% of all other covered expenses. So for this example the Insured would pay $2,000 and the Insurer would pay $8,000.


Claim Scrubbing
It is a method designed to detect claim coding and compliance issues before submission for reimbursement. Identifying claim errors efficiently can dramatically accelerate practice's reimbursement cycle and detect system inefficiencies.

Electronic Claim Processing
This is the processing medical claim electronically which had many benefits like, receives priority processing, Electronic medical claims submitted go directly to the payer's processing unit, ensuring faster turnaround. Paper claims are processed only after manual sorting and batching.
Many practices are turning to electronic claims processing because of the vast time and money savings that result. Processing insurance claims electronically improves cash flow, reduces the expense of claims processing and streamlines internal processes allowing a practice to focus on patient care.

The reduction in insurance reimbursement time results in a significant increase in cash available for the needs of a growing practice. In addition, by reducing the internal expenses associated with processing paper claims, reduced labor, office supplies and postage all contribute to the bottom of the practice when submitting claims electronically.

Super bill
A modified claim form that lists specific and/or specialty medical services provided by a physician. It cannot be used in place of the standard AMA form.

Capitation
Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment "per covered life" or per member.

The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered.
The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization.

Assignment of Benefits
An arrangement by which a patient requests that their health benefit payments be made directly to a designated person or facility, such as a physician or hospital.