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Find definitions to common insurance and reimbursement terms, as well as terms associated with Cephalon Oncology products.
Adjudication — process used to receive payment for a claim.
Advance Beneficiary Notice — written notification given to a patient that payment may be denied or reduced, thereby holding the patient responsible for any residual amount.
Ambulatory Payment Classification — part of Medicare's Outpatient Prospective Payment System for hospital outpatient clinics.
Appeal — process for reconsideration of a denied claim.
Assignment — agreement that a provider will bill Medicare directly and accept the allowable amount of payment.
Average Sales Price — average price from the manufacturer, net of all discounts, rebates, charge-backs, and credits for drugs.
Average Wholesale Price — suggested retail price determined by the manufacturer.
Carrier — insurer contracted by Medicare to administer Medicare Part B benefits.
Case Management — management of a specific patient's care by a registered nurse or other qualified individual.
Centers for Medicare and Medicaid Services — agency charged with administering Medicare and Medicaid.
Charge Description Master — central file containing billing elements for all generated charges.
Claim — information submitted to insurers requesting payment for covered services.
CMS 1500 — claim form used to submit claims for Medicare Part B.
Commercial Carriers — for-profit insurance companies offering health insurance.
Copayment — amount not covered by insurers; the patient is responsible for paying.
CPT Code — Current Procedural Terminology. Multiple codes are acceptable to use for an appointment with multiple procedures.
Current Procedural Terminology — numeric codes supplied by the American Medical Association used to charge for physicians' services.
Deductible — fixed payment a patient must make before insurer provides coverage.
Diagnosis-Related Groups — classification of diagnoses for the purpose of hospital reimbursement in the Inpatient Prospective Payment System.
Dual Eligibility — eligible for both Medicaid and Medicare.
Durable Medical Equipment — medical equipment used repeatedly in the treatment of illness and injury.
Evaluation and Management Codes — included in the current procedural terminology codes to classify cognitive services performed for patients by healthcare providers.
Fiscal Intermediary — insurance company contracted by the Centers for Medicare and Medicaid Services to administer Medicare Part A.
Healthcare Common Procedure Codes — billing codes used to submit claims for procedures, supplies, drugs, and physician services.
Health Maintenance Organization — health plan in which members are required to use a network of providers for a specific time period.
HIPAA — Health Insurance Portability and Accountability Act of 1996. This law relates to underwriting, pre-existing limitations, guaranteed renewal, COBRA, and certification requirements in the event someone terminates from the plan. It establishes new requirements for self-funded, fully insured group plans (including church plans), and individual health policies.
Incident to Services — services or supplies provided by a physician, used as an integral but incidental part of diagnosing and treatment of injuries or illness of Medicare B-covered patients, usually excluding drugs that can be self-administered.
Innovator Multi-Source Drugs — brand name drugs with generic equivalents.
Inpatient Prospective Payment System — used by the Centers for Medicare and Medicaid Services to determine payment of claims.
Intermediaries — insurers who have a contract with the Centers for Medicare and Medicaid Services to process Medicare Part A claims.
International Classification of Diseases, 9th Edition — codes used to classify diseases, symptoms, conditions, and procedures.
Major Diagnostic Category — used in Diagnosis-Related Groups reimbursement by classifying diagnoses grouped according to body system.
Medicaid — Centers for Medicare and Medicaid Services program administered by both federal and state governments providing coverage for needy people of all ages. Programs vary by state.
Medicare — Medicare is the federal-funded health insurance initiative, which many of the privately funded health insurance providers follow for what claims are paid and which ones are not.
Medicare Part A — program administered through intermediaries by the Medicare and Medicaid Services to cover inpatient care.
Medicare Part B — program administered through carriers by the Centers for Medicare and Medicaid Services to cover outpatient care.
Medicare Part C — optional purchased coverage in addition to Medicare Part A and B. Examples include Medicare + Choice and Medicare Risk Plus. Includes managed care plans.
Medicare Part D — new Medicare plan providing prescription drug coverage for Medicare recipients that will be offered in 2006.
Medicare Prescription Drug, Improvement and Modernization Act — act signed into law on December 8, 2003, designed to improve benefits to seniors and disabled people. Includes a prescription drug benefit.
Medigap — supplemental insurance for Medicare recipients sold by private insurance companies.
Non-Innovator Multi-Source Drugs — generic medications.
Outlier — medical cases with higher-than-average established cost or length of stay.
Outpatient Prospective Payment System — used by the Centers for Medicare and Medicaid Services to determine payment of claims submitted for inpatients with Medicare.
Packaged Drugs — drugs whose costs are packaged into the payment for the assigned Ambulatory Payment Classification, and not separately reimbursed.
Pass-Through Drugs — drugs designated for a maximum of two to three years to be reimbursed separately from Ambulatory Payment Classifications prior to determination of payment method by the Outpatient Prospective Payment System.
Pre-Certification — an insurance company requirement that an insured obtain pre-approval before being admitted to a hospital or receiving certain kinds of treatment.
Preferred Provider Organization — fee-for-service organization offering a variety of plans and contracts with providers to pay a discounted fee for their services.
Relative Value Unit — weight assigned to current procedural terminology codes representing value based on the complexity of service.
Revenue Codes — billing code used by hospitals to identify cost centers affiliated with services, pharmaceuticals, and supplies charged to Medicare patients. Also referred to as UB-92 codes.
Self-Administered Drugs — non-covered injectable medications not usually self-administered by more than 50% of outpatients.
Sole Source Drugs — brand name drugs without generic equivalents.
Specified Covered Outpatient Drugs — covered drugs assigned an Ambulatory Payment Classification for which the designation of pass-through (separate) payment was made prior to 12/31/2002.
Status Indicators — list of alphabetical codes used to determine if a drug is paid separately under the Outpatient Prospective Payment System.
TRICARE — triple-option healthcare program bringing together the Civilian Health and Medical Program of the Uniformed Services as well as the healthcare delivery services of each of the military services.
UB-92 — synonymous with the CMS-1450 form used by hospitals to file Medicare claims for services rendered to both inpatients and outpatients.
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