Allowable fee - ANSWER Average or maximum amount the third-party payer will reimburse providers for the service
Block grant - ANSWER It is a fixed amount of money given or allocated for a specific purpose. Ex. Medicare's payment system for home health services are consolidated into the single pa...
Allowable fee - ANSWER Average or maximum amount the third-party payer will reimburse providers for
the service
Block grant - ANSWER It is a fixed amount of money given or allocated for a specific purpose. Ex.
Medicare's payment system for home health services are consolidated into the single payment
Capitated payment method - ANSWER It is a method of payment for health services in which the third-
party payer reimburses providers a fixed, per capita amount for a period. "Per capita" means "per head"
Case-based payment - ANSWER Type of prospective payment method in which the third-party payer
reimburses the provider a fixed, preestablished payment for each case
Adjacent episodes of care - ANSWER Episodes of home health that are contiguous and separated by no
more than 6 days
Adjudication - ANSWER The determination of the reimbursement payment based upon the member's
insurance benefits
Adverse selection - ANSWER Enrollment of excessive proportion of persons with poor health status in a
healthcare plan or healthcare organization
RBRVS - ANSWER The federal government's payment system for physicians. It is a system of classifying
health services based on the cost of furnishing physicians' services in different settings, the skill and
training levels required to perform the services, and the time and risk involved
Clustering - ANSWER Coding or charging one or two middle levels of service codes exclusively
AHA's Coding Clinic for ICD-10 CM/PCS - ANSWER It allows coders to submit a request for coding advice
through the coding publication. It is the only official publication for ICD-10-CM/PCS
, Major diagnostic categories - ANSWER MS diagnostic-related groups are organized into this
AHA Coding Clinic for HCPCS - ANSWER Official coding guidance for HCPCS Level II procedure, service,
and supply codes
Ambulatory payment classification - ANSWER Hospital outpatient prospective payment system. The
classification is a resource-based reimbursement system
Ambulatory payment classification group - ANSWER They are based on HCPCS/CPT codes. A single visit
can result in multiple groups. There are five types of service: significant procedures, surgical services,
medical visits, ancillary services, and partial hospitalization
Ancillary services - ANSWER Professional healthcare services such as radiology, laboratory, or physical
therapy
Base rate - ANSWER Rate per discharge for operating and capital-related components for an acute care
hospital
Base year - ANSWER Most recent 12-month period for which the Centers for Medicare and Medicaid
Services has complete and available data upon which to calculate and calibrate rates and weights
Budget neutrality - ANSWER Adjusting payment rates so total expenditures are equal to specified past
periods, often mandated under federal acts and regulations
Budget neutrality adjustor - ANSWER Percentage, weight, proportion, or other mechanism that alters
payment in order to maintain budget neutrality
Bundling - ANSWER Combination of supply and pharmaceutical costs or medical visits with associated
procedures or services for one lump sum payment
Carrier - ANSWER Entity that has a contract with the Centers for Medicare and Medicaid Services (CMS)
to determine and make Medicare payments for Part B benefits
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