Examples include a hospital, a critical care facility, a skilled nursing facility, a home health agency or hospice.
What is an Institutional Provider?
100
The cost of the drug minus the dispensing fee, sales tax, etc.
What is the Ingredient Cost?
100
The form filled out by the provider to describe services performed on a patient for a professional claim.
What is the CMS-1500 (HCFA)?
100
A combination of HMO and PPO that offers two tiers of coverage: in-network and out-of network.
What is a POS?
200
0483: Echocardiology.
What is a Revenue Code?
200
A participant or beneficiary of a health benefit plan that is receiving medicare care.
What is a Patient?
200
Copy of a brand name drug.
What is a Generic Drug?
200
A statement sent by a health insurance company to patients explaining what medical treatments and/or services were paid for on their behalf.
What is an Explanation of Benefits (EOB)?
200
Primary Care Physician is generally required and they act as a gatekeeper for authorization and referrals to specialists.
What is an HMO?
300
307.81: Tension headache.
What is an ICD-9 Code?
300
Someone who ordered, referred, or certified item or service in the claim.
What is a Referring Provider?
300
Universal product identifier for non prescription and prescription medication.
What is a National Drug Code (NDC)?
300
The form filled out by the provider to describe services performed on a patient for a facility claim.
What is a CMS-1450 (UB-04)?
300
Primary Care physician and referrals are not required, but there's a limited network of doctors and hospitals to choose from.
What is an EPO?
400
Y93.D1: Accident while knitting or crocheting.
What is an ICD-10 Code?
400
Tax reporting entity to which insurance companies send reimbursement for claim submitted.
What is the Billing Provider?
400
Amount reimbursed to the pharmacy to cover the cost of professional services and overhead costs. This is typically $1.10-$1.80 per prescription.
What is a Dispensing Fee?
400
The decision whether to pay or deny a claim.
What is a Claim Adjudication?
400
The patient drives their own care, with no agreements with providers, and reimbursement is often based on the UCR rate.
What is an Indemnity?
500
76: Repeat procedure by the same physician.
What is a CPT Modifier?
500
Hired by a self-insured plan administrator, they manage processing, payment, and settlement of claims and other administrative tasks.
What is a Third Party Administrator (TPA)?
500
Drugs that are available in both brand-name and generic forms.
What is a Multiple-Source Drug?
500
Action participant takes if the participant disagrees with a benefit plan's adjudication decision.
What is an Appeal?
500
A type of health coverage that offers two tiers of coverage with high levels of flexibility: in-network, where the plan and provider have a contract where the payments are set, and out-of-network, where the provider doesn't have contract.