HHP 435

• Current Procedure Terminology
• 5 digit codes used to identify specific medical services

• International Classification of Diseases
• 3, 4, & 5 digit codes used to identify specific injury/disease diagnoses

• Healthcare Common Procudure Coding System
• Required for reimbursement of Durable Medical Equipment (DME)
• Letter followed by 4 digits

Person eligible to recieve benefits of an insurance policy

Person eligible to receive benefits of an insurance policy by virtue of relationship to policy holder

Outline of services covered by insurer/employer

Specified services, procedures, disorders, and durable medical equipment (DME) that are not covered by a health plan

• service provider who has entered into contrct with a payer
• acceptance of payer fee schedule or discounted rates
• no balance billing
• full charge to patient for uncovered services

form for documentation of diagnosis and procedures administered on a specific service date

• form sent to insurance company of TPA requesting payment for medical services provided to benificiary
• CMS-1500(medicare) or UB-92(hospitals)

Claim form containing all info necessary for processing

report explaining how an insurance company or TPA processed a claim

Often designated as an excluded degenerative conditon by payors

generally considered as a covered injury

intentional deception or misrepresentation that an individual knows to be false, or does not believe to be true, and makes knowing that the deception could results in some unauthorized benefit to himself or some other person

• 1. offering or accepting kickbacks
• 2. waiver of deductible/coinsurance