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Claims Terminology Review
| Questions |
Answers |
| An amount owed to a healthplan from a provider. Advances result from a health plan member's retroactive termination from a health plan, the reversal of a previously paid claim, or a payment made to a provider for claims not yet processed. Advances are app |
Advance |
| Situations where another party is liable for the cost of medical care provided to a member. Primary third parties are auto insurance, commercial liability, workers compensation, malpractice, etc. |
Third Party Liability |
| A manual or system generated message for the provider that explains why a claim paid or denied in a specified manner |
Remit |
| A payment methodology in which the physician is paid a set dollar amount determine by per member per month calculation to deliver medical services to a specified group of people. |
Capitation |
| Refers to the current standing of a claim or referral. |
Status |
| A organized procedure carries out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use. |
Utilization Management |
| All services are paid within the primary procedure and other services pay $0.00 |
All Inclusive |
