A

  • Adjudicate - to determine whether a claim is to be paid or disallowed.
  • Adjuster - an individual often referred to as a claims representative, who acts for an insurance company in the settlement of a medical claim.
  • Adjustments - changes made to correct an error in billing, processing of a claim or as a result of retroactive rate change.
  • Allowed charges - that part of the reported charge that qualifies as a covered benefit, eligible for payment.
  • Assignment of benefits - an agreement between the insured and provider which authorizes the insurance carrier to pay benefits directly to the provider of services.
  • Attending physician - the physician in charge of the patient's medical care.

B

  • Beneficiary - a person eligible to receive benefits under a health care plan.
  • Benefit - an amount payable by an insurance plan or Medicaid for services covered by the plan.
  • Birthday rule - the rule associated with the process of coordination of benefits in which when both parents have health care coverage, the insurer of the parent whose birthday falls first in a calendar year becomes the primary carrier.

C

  • Capitation - a method of payment for health care services in which the provider is paid a fixed fee for each person enrolled in an insurance plan. The monetary allowance for each enrollee is usually based on average costs adjusted for age, sex, and so forth, not on the type or number of services rendered to individual patients.
  • Carrier - the insurance company, HMO or PPO which writes, underwrites, and/or administers the health insurance policy, HMO or PPO Plan, also referred to as the insurer.
  • Civilian Health and Medical Program of the Uniformed Services (Champus) - the federally funded health benefits program designed to provide the military personnel and eligible beneficiaries a supplement to medical care provided in military and public health service facilities, such as for services received in another facility not connected to the military base services.
  • Claim - the written or electronically submitted request for payment of benefits for covered services; standardized claim forms include the HCFA/CMS 1500 and DPA 1443.
  • COBRA - (Consolidated Omnibus Reconciliation Act of 1985) - federal legislation which mandates to some persons who would otherwise lose group health insurance coverage the right to continue coverage under the group plan for a limited time period. Employees who terminate employment for any reason other than gross misconduct, those whose hours are reduced, and dependents of these employees may continue the group coverage for up to 18 months. Dependents may continue coverage for up to 36 months if they lose coverage for any of the following reasons: death of the employee, divorce from the employee, reaching the maximum age allowed under the policy, or employee eligibility for Medicare. Premium costs for COBRA coverage are borne entirely by the insured and may total up to 102% of the total employer/employee premium contribution under the group plan.
  • Coinsurance (Co-payment) - a provision of an insurance plan which stipulates the beneficiary's share of the cost of covered services, usually stated as a percentage of allowed charges.
  • Comprehensive medical insurance - a policy which provides both basic and major medical health insurance protection. Benefits are usually paid at a set percentage of all covered charges after satisfaction of a periodic deductible.
  • Congenital anomaly - a medical condition, present at birth, which is significantly different from the norm.
  • Consent - voluntary agreement, based on an understanding of the nature of a particular action and the risks involved.
  • Consultation - direct intervention with the child, parent or LEA staff about the treatment plan of the child.
  • Coordination of benefits (COB) - when a patient covered by more than one insurance, the plan provides for carriers to take into account benefits payable by another plan and determine primary and secondary responsibility.
  • Covered services - those health care services provided to the patient which are stipulated by an insurance plan as eligible for benefit payments.
  • Customary charge - a dollar amount representing the lowest charge to a client, including any discount, for a specific service during a specific period of time by an individual provider.
  • Current Procedural Terminology (CPT-4) - listing of medical terms and identifying codes for reporting medical services and procedures, developed by the American Medical Association.

D

  • Deductible - specific dollars outlined in the insurance plan that must be paid before the benefits of the plan become payable.
  • Deductible Carryover - allows for covered services incurred within the last three months of the year to be carried over and counted toward the next year's deductible.
  • Denial - a claim for which payment is disallowed.
  • Dependent - those individuals, other than the insured, who are eligible for coverage under the plan; generally, the insured's spouse and children
  • Diagnosis - the identity of a condition, cause or disease
  • Direct service - professional services provided in a face-to-face contact with the child.
  • Direct supervision - supervisor (licensed/certified personnel) physically present on school premises while services are being provided with the possibility of face-to-face contact with the person being supervised.
  • Disallow - to determine that a billed service(s) is not covered by Medicaid and will not be paid.
  • Disability income insurance - a type of health insurance that provides periodic payment, in replacement of income, when an insured is disabled due to illness, injury or disease.
  • DOS - date of service
  • Duplicate claim - a claim which has been submitted or paid previously.
  • Durable medical equipment - equipment which (1) can withstand repeated use and (2) is used to serve a medical purpose. Example: a wheelchair

E

  • Electronic claim - processing and delivery of a claim from one computer to another through a form of magnetic tape or telecommunications.
  • Eligible - one who is qualified for benefits.
  • Eligibility file - a file containing individual records for all persons who are eligible for coverage by the plan.
  • EOB - (Explanation of Benefits) - written statement from the third-party payer which explains details of benefit calculations.
  • EPSDT - Early and Periodic Screening, Diagnosis and Treatment, a federally mandated program for eligible individuals under the age of 21.
  • ERISA- (Employee Retirement Income Security Act) - Congressionally enacted pension reform legislation of 1974 that includes stipulations which have evolved to provide insulation for self-funded plans, from individual state's insurance regulations.
  • Error code - a numeric code indicating the type of error found in processing a Medicaid claim.
  • Exclusions - services, conditions, or products which are specifically listed in a policy as not covered.

F

  • Fee for service - payment by a third-party payer to providers of health services of specific amounts for service given.
  • Fiscal agent - an organization authorized to process claims.

G

  • Gatekeeper - refers to the physician(s) in prepaid health care plans who perform initial medical exams or screen prospective care prior to referral to other specialists or allied health professionals within or outside the plan.

H

  • Healthcare Financing Administration (HCFA) - federal governmental agency responsible for the administration of the Medicare and Medicaid programs under the auspices of the Department of Health and Human Services.
  • Healthcare Financing Administration Common Procedure Coding System (HCPCS) - includes three levels of standardized procedure codes:
    • Level 1 codes are CPT numeric procedure codes:
    • Level 2 are national, HCFA, alpha-numeric (A through V) codes for procedures not included in CPT codes; and
    • Level 3 are local (state) alpha-numeric codes (W through Z) for procedures to meet local coding needs.
  • Health Maintenance Organization (HMO) - an alternative delivery system in which enrollees pay a fixed payment for comprehensive health care services emphasizing preventative and primary care.

I

  • Indirect service - directing the teachers/aides in providing related services in the classroom as nondirect intervention with the child.
  • Insured - the person who is the primary policy holder in relation to the insurance plan.
  • Intermediary - insurance carrier or data processing company which processes Medicare or Medicaid claims on behalf of the government.
  • International Classification of Diseases, 9th Revision, Clinical Modifications(ICD-9-CM) - coding manual developed by the National Center for Health Statistics and others to standardize disease and procedures classification. A listing used by providers in coding diagnosis on claims.

L

  • Long-term disability income insurance - a policy that pays benefits to a disabled person for as long as the person is disabled, within policy limitations.

M

  • Major medical insurance - health insurance policy that provides for reimbursement of major illness and injury to insured, usually includes a deductible then provides for expansive benefits.
  • Maximums - upper dollar limit a carrier will reimburse for a specific benefit or policy.
  • Medicaid - a government-sponsored medical assistance program that enables eligible recipients to obtain medical benefits outlined within the state Medicaid guidelines.
  • Medically needy - individuals whose income and resources equal or exceed those levels for assistance established under a State or Federal plan, but are insufficient to meet their costs of health and medical services.
  • Medical necessity - a service reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a disability or cause physical deformity or malfunction, and if there is no other equally effective course of treatment available or suitable for the recipient requesting the service.
  • Medical record - data or information retained in some media form and related to the health status of and treatment rendered to a patient.

N

  • Non-covered services - (1) services not medically necessary; (2) services provided for the personal convenience of the patient; or (3) services not covered under the health care plan.
  • Non-participating Provider (NonPar) - a provider who has not both signed a contract with a carrier (HMO or PPO) nor agreed to provide services under the terms of the carrier and/or specific plan.

O

  • Overutilization - any usage of health care programs by providers and/or recipients not in conformance with both State and Federal regulations and laws (include fraud, abuse and defects in level and quality of care).

P

  • Participating provider - a medical care provider who has established a contractual relationship with a third-party payer to provide certain services to members of a plan.
  • Payment - reimbursement to the provider of services for a claim incurred that is a covered benefit.
  • Peer Review Organization - the utilization and quality control review unit that reviews the validity of diagnostic information: the completeness, adequacy and quality of care provided; the appropriateness of admissions and discharges; and the appropriateness of services provided. Many professional associations have established quality of care and peer review organizations, standards and committees who complete the review process.
  • Plan of Care - written statement that details the patient's condition, functional level, treatment goals and objectives, the physician's modifications to the plan, and plans for ongoing care, and potential for discharge from treatment.
  • POS - place of service.
  • Precertification - the process of providing required notice of proposed treatment to the patient's third-party payer.
  • Pre-existing Condition - an injury, disease, or disability that afflicted the insured prior to issuance of the insurance policy, and which frequently excludes the insured from coverage totally or for a specific period of time.
  • Preferred Provider Organization (PPO) - a PPO is similar to an HMO that uses the open panel plan of preferred providers. Individual health care practitioners become preferred providers and are paid on a negotiated fee-for-service basis by a purchaser group. The patient routinely participates in the health care plan of a commercial carrier, which monitors utilization of service.
  • Primary carrier - insurance carrier or HMO/PPO which has first responsibility for payment under coordination of benefits.
  • Primary diagnosis - the condition considered to be the patient's major health problem for which treatment is rendered and on which the physician's claim is based.
  • Prior authorization - process of obtaining permission, to provide services, from the carrier who will reimburse the service.
  • Procedure code - a statistically based code number used to identify medical procedures performed by a provider.
  • Progress note - a dated, written notation in the child's record detailing an encounter with the child and the child's response to the encounter.
  • Provider - the person, professional, or group practice certified to provide covered health care services to the child.
  • Provider agreement - a contract between the provider and carrier that states the conditions of participation and reimbursement.
  • Provider number - a nine-character code assigned to each provider of Medicaid services in Illinois for identification purposes.

Q

  • Quality assurance program - activities that measure the kind and degree of excellence of health care delivered. Quality of care is measured against preestablished standards. There are federal and state guidelines that relate to quality assurance programs within HMOs.

R

  • Reimbursement - the amount of money remitted to a provider.
  • Rejected claim - a claim for which payment is refused as not meeting the minimum guideline of the Medicaid Program.
  • Release of Information - the patient's (or parent or guardian's) signature on a consent form that allows the release of information necessary to the settlement of the claim.

S

  • Screening - the use of quick, simple medical procedures carried out among large groups of people to sort out apparently well persons from those who have a disease or abnormality and identify those in need of more definitive examination or treatment.
  • Secondary carrier - the insurance carrier that is second in responsibility within the coordination of benefits.
  • Suspended claim - "in process claim" which must be reviewed and resolved.

T

  • Third-party payer - a public or private entity that insures against risk of loss or reimburses for expenses incurred in relation to the receipt of medical care services.

U

  • UCR - (usual customary reasonable) - a third-party's method of benefit calculation which takes into account charges billed by all providers within a particular discipline and geographic region.
  • Unit - a session of therapeutic treatment or diagnostic assessment.