These are standard terms used within the majority of our reimbursement policies. For specific policy related definitions, please view the individual policy. Provider and/or state contract definitions supersede the definitions listed below.
Benefits: services covered by a health benefit plan and which the member may be eligible for, specific to her/his enrolled health plan
Bundled service: an individual service that is included in a more complex or comprehensive service and billed on the same date of service as the more comprehensive service
Code editing logic: a review and evaluation tool for accuracy and adherence of medical claims to accepted national industry standards, state standards, plan benefits and authorization guidelines
Code set: under HIPAA, code sets are any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnostic codes or medical procedure codes
Consistency guidelines: system logic that identifies services that are inconsistent in nature, including:
Continuity of care: continuance of care or services rendered by a provider for the purpose of continued treatment due to the complexity or advanced phase of the medical condition for members who are newly enrolled and/or who need to avoid a lapse in care for a medical condition requiring continued care; continuity of care can also be established for existing members who have conditions that require treatment by a provider not currently in, or recently terminated voluntarily from, the network
Covered services: medically necessary health services, as determined by the plan and described in the applicable health benefit plan, for which a member is eligible for coverage
Encounter: record of a medically related service (or visit) rendered by a provider to a beneficiary who is enrolled in a participating health plan during the date of service; it includes, but is not limited to, all services for which the health plan incurred any financial responsibility
Episode of care: a single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition
Facility-based provider: a hospital, nursing home, or other medical or health-related service facility that provides care for the sick, injured or disabled or other care that may be a covered service in a health benefit plan
Fee schedule: the complete listing of health plan rate(s) for specific services that represents payment for each unit of service allowed based on applicable coded service identifier(s) for covered services
Global allowance: reimbursement for certain services or surgical procedures that are considered to be directly related to a procedure's global allowance will be considered integral/inclusive to that service and not allowed separate reimbursement; reimbursement for surgical procedures includes the preoperative services, surgical operation and uncomplicated postoperative-care visits
Global period: a global period is the number of days prior to and/or following a procedure during which other necessary related services furnished by a provider are included in the global reimbursement allowance for a procedure
Incidental procedure: an incidental procedure is performed at the same time as a more complex primary procedure; the incidental procedure requires minimum additional resources and/or is clinically integral to the performance of the primary procedure; procedures that are considered incidental when billed with related primary procedures on the same date of service will be denied
Level of care: the intensity of medically necessary medical care required to achieve the treatment objectives
Maximum allowance: the maximum amount a plan will pay for a covered health care service
Medical necessity criteria: medically necessary services are all services that a medical practitioner exercising prudent clinical judgment would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, or disease or its symptoms, and that are:
Medical records: reports, notes, photographs, X-rays, or other recorded data or information (whether maintained in written, electronic or another form) that is received or produced by a health care provider or any person employed by the provider to document an episode of care, or encounter of service; these items contain information relating to the medical history, examination, diagnosis or treatment of the member for an identified episode of care or encounter for specific dates of service
Modifier: modifiers are two-digit codes appended to a CPT or HCPCS code when appropriate; a modifier can consist of numeric or alphanumeric characters; modifiers provide payers with the additional information needed to process a claim, and they allow providers to indicate that a service for which the basic code description has not changed in definition but was altered or affected by some special circumstance
Mutually exclusive procedures: two or more procedures that cannot usually be successfully performed together on the same patient and/or differ in technique or approach but lead to the same outcome; an initial service and subsequent service of this nature are considered mutually exclusive, and only one of the procedures is considered a covered service when medically necessary
Prior authorization: an approval process for requested medical services, either by a servicing health care provider or the patient, to determine if a service is covered for reimbursement; prior authorization is determined by eligibility, plan benefits and medical necessity of the service being requested
Recoupment of payments: retraction of monies paid to providers by offsetting future payments
Recovery of payments: request for the provider to return payment
Routine medical and surgical supplies: supplies that are customarily used in small quantities, usually included in the provider's supplies and not designated for a specific patient