American Academy of Professional Coders (AAPC)
Offers 5 certification exams and was established to provide a national certification &credentialing process, to support the national & local membership by providing educational products & opportunities to network, & to increase & promote national recognit
American Health Information Management Association (AHIMA)
professional organization for health information personnel
American Medical Billing Association (AMBA)
Offers the Certified Medical Reimbursement Specialist (CMRS) exam, which recognizes the competency of members who have met high standards of proficiency.
Bonding Insurance
an insurance agreement that guarantees repayment for financial losses resulting from an employee's act or failure to act. It protects the financial operations of the employer.
Centers for Medicare and Medicaid Services (CMS)
Federal agency within the Dept. of Health and Human Services and runs Medicare, Medicaid Clinical Laboratories. Formerly Heath Care Financing Administration.
Coding
The process of assigning standardized codes to diagnoses and procedures. A transference of words into numbers so computers can be used in claims processing.
Current Procedural Terminology (CPT)
CPT, A reference procedural code book using a five-digit alpha-numerical system to identify and code procedures established by the American Medical Association
Electronic Claims Processing
Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing
Electronic Data Interchange (EDI)
Computerized submission of health care insurance information exchange, the exchange of routine business transactions from one computer to another using publicly available communications protocols.
Embezzle
appropriate (as property entrusted to one's care) fraudulently to one's own use
Errors and Ommissions Insurance
Provides protection from claims that contain errors and ommissions resulting from professional services provided to clients as expected of a person in the contractor's profession.
Ethics
The principles of right and wrong that guide an individual in making decisions; a set of moral principles or values.
Explanation of Benefits (EOB)
a document from a payer sent to a patient that shows how the amount of benefit was deteremined.
HCPCS level II codes
National Codes published by CMS includes five-digit alphanumeric codes for procedures, services and supplies not classified in CPT.
Healthcare Common Procedure Coding System (HCPCS
A three-tier national uniform coding system developed by the Centers for Medicare and Medicaid Services, formerly HCFA, used for reporting physician or supplier services and procedures under the Medicare program. Level I codes are national CPT codes. Leve
Health Care Provider
A provider of medical or health services and any other person or organization who furnishes bills or is paid for health care in the normal course of business.
Health Information Technician
Organize and code patient records, gather statistical data.
Health Insurance Claim
Documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided.
Health Insurance Specialist
Person who reviews health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider. Also called: Reimbursement specialist.
Hold Harmless Clause
In the contract, the health care provider cannot collect the fees from the patient. (Patient is not responsible for paying what the insurance plan denies.)
Independent Contractor
one who contracts to do something for another but is free of the latter's direction and control
International Classification of Diseases, 9th edition, Clinical Modification (ICD 9 CM)
Alphanumeric diagnoses codes. May be up to 5 digits.
Liability Insurance
insurance designed to cover a policyholder for acts or omissions for which he or she may be legally obligated.
Medical Malpractice Insurance
a type of liability insurance that covers physicians and other healthcare professionals for liability claims arising from patient treatment
Medical Necessity
Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient's symptoms and diagnosis., The diagnosis that proves the services rendered were consistent with th
National Codes
HCPCS Level II Codes. 5 digit Alphanumeric codes for procedures, services, and supplies not classified in CPT.
Preauthorization
A requirement of some health insurance plans to obtain permission for a service or procedure before it is done to see whether the insurance program agrees it is medically necessary. If not done prior to receiving care, the charges are usually denied and t
Professional Liability Insurance
Protects individuals and organizations that provide professional services when they are held liable for the losses of their clients.
Property Insurance
insurance that covers for losses resulting from perils such as fire, theft, or windstorm
Reimbursement Specialist
Review health-related claims to determine the medical necessity for procedures or services performed before payment is made to the provider. AKA Health Insurance Specialist
Remittance Advice
a document sent by an insurance carrier that lists services obtained and the reimbursements, or reasons for lack of reimbursement
Respondeat Superior
Let the master answer" an employer is vicariously liable for the behavior of an employee working within his or her scope of employment
Scope of Practice
Defines the profession, delineates qualifications, and responsibilities, and clarifies supervision requirements.
Worker's Compensation Insurance
A state or federal plan that covers medical care and other benefits for employees who suffer accidental injury or become ill as a result of employment.