| A | B |
|---|
| Clinical Laboratory Improvement Amendments | a 10-digit lab.certification # in form locator 23 which must be included when lab. services are performed on-site |
| Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) | requires employers to allow employees, their spouses and their dependents to continue group health insurance coverage for a minimum of 18 months after their employment with the company ends |
| cost contract | one of two Medicare contracts with HMOs where a patient may either see providers within the plan's network (subject to copayment) or go outside network as a fee-for-service Medicare claim |
| fiscal intermediaries | Insurance companies that process claims for hospitals, skilled nursing facilities, intermediate care facilities, long term care facilities, and health care agencies |
| limiting charge | 115% of the fee listed in the nonPAR Medical Fee Schedule |
| Local Medicare Review PolicyLMRP) | notices sent to physicians on a regular basis containing detailed asnd updated information about the coding and medical necessity of a specific service |
| Medical Savings Account(MSA) | trial program in which a savings accunt is set up to pay future medical bills |
| Medicare Part A | pays for inpatient hospital care, skilled nursing facility care, home health care, respite care, and hospice care. Anyone receiving ss benefits is automatically enrolled in part A |
| Medicare Part B | helps pay for many procedures and suppies, including outpatient services deemed medically necessary.Those eligible: those entitled to part A benefits, U.S. citizens and permanent residents over 65, |
| Medicare + Choice | group of insurance plans under Medicare, part B |
| some items in a Local Medical Review Policy | description of service,list of indications, appropriate HCPCS code,appropriate ICD-9 code,bibliography containing recent clinical articles to support Medicare policy |
| 3 main types of Medicare + choice plans: | 1) coordinated care plan(incl. HMO and POS); 2)Medical Savings Account (individuals select a high-deductible while gov. pays into insurance savings fund for each enrollee;3) Private fee-for-service plan (unrestricted plan allows choice from private providers) |
| Medicare Remittance Notice | notice from payers that summarizes a batch of claims, rather than a separate EOMB for each claim |
| Medigap | private insurance that beneficiaries may purchase to fill in some of the unpaid amounts in Medicare coverage |
| items Medigap will cover | annual deductible, any required coinsurance, prescription drugs |
| Peer Review Organization (PRO) | state-based group of physicians paid by the government to review aspects of the Medicare program, including quality and appropriateness of services provided and fees charged. |
| provider-sponsored organization (PSO) | similar to HMO, but the physicians and hospitals that provide treatment also own and operate the plan |
| risk contract | requires patient to receive treatment within his HMO network.If patient goes out of network for services, patient must pay entire cost.(restriction does not apply to emergency treatment or urgently needed care) |
| supplemental insurance | plan that an individual may purchase when retiring from a company, which provides additional coverage for one receivinig benefits under Medicare, part B |
| urgently needed care | care provided while temporarily outside the plan's network area |
