CAD
Covered, Authorized, Dollar
UCR
Usual, Reasonable, and Customary
the amount paid for a medical service in a geographic area based on the providers in the area/similar medical service
UCR - ANSWER-Usual, Reasonable, and Customary
the amount paid for a medical service in a geographic area based on the
providers in the area/similar medical service
Subscriber - ANSWER-The one who owns the policy
Guarantor - ANSWER-Person responsible for out of pocket expenses
In network/participating provider - ANSWER-provider has a contract with the
insurance company and agrees to accept the allowed payment amounts by the
insurance as full payment.
Out of network/non participating provider: - ANSWER-not under contract/can
balance bill
Deductible - ANSWER-the amount of expenses that must be paid out of pocket
before an insurer will cover any expenses
High deductible = lower premium
lower deductible = higher premium
Coinsurance - ANSWER-the amount of expenses that must be paid out of pocket
before an insurer will cover any expenses
Copayment - ANSWER-fixed amount your health insurance may require you to
pay for a specific medical service or supply
, Pre-certification - ANSWER-confirming that the procedure is covered under the
policy
Pre-authorization - ANSWER-determining the maximum dollar ($) amount that the
insurance company will pay
Coordination of benefits - ANSWER-used to establish the order in which health
insurance plan pay claims when more than one plan exists
ICD-10-CM - ANSWER-International Classification of Diseases, 10th Revision,
Clinical Modification
1) 3-7 characters in length
2) Very specific
3) Digit 1: alpha
4) Digit ⅔: numeric (A12) etc
5) 4/7: alpha or numeric
6) XXX.XXX X (category. Etiology, anatomic site, severity. extension)
7) USE FOR CLAIMS WITH A DATE OF SERVICE AFTER OCTOBER 1, 2015
CPT - ANSWER-Current Procedural Terminology
HCPCS - ANSWER-Healthcare Common Procedural Coding System Level II
ICD-9-CM - ANSWER-ONLY USE FOR DATES OF SERVICES ON OR BEFORE
SEPTEMBER 30, 2015
International Classification of Diseases, 9th Revision, Clinical Modification
3-5 characters in length
WHO: world health organization
First digit may be alpha or numeric
Digits 2-5 are numeric
XXX.XX (category. Etiology, anatomic site, manifestation)
ICD-10-CM Conventions - ANSWER-NEC: Not elsewhere classified
Identifies codes/index terms that specify a condition or disease which there is no
separate code to identify it
NOS: - ANSWER-Not Otherwise Specified
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