language.docx - Monay Ross Reimbursement Language 1 Medical...

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Monay Ross 05/30/2019 Reimbursement Language 1. Medical necessity - Are health care services that a physician would provide to a patient. It is also something that insurances look at to determine if payment will be made. A certain criteria must be met to determine coverage. 2. Difference between fraud & Abuse - Fraud is an act that represents a crime against payers or other health care programs for example billing Medicare for services or supplies not provided. abuse is reimbursement for services not medically necessary or failure to meet certain required standard. 3. Personal Identifier - Is a data element within a data set that can uniquely identify a person. This requirement Has been withdrawn. Difference HHS delayed any work on this standard until after privacy protections were in place. 4. NPI - Is a standard created by HIPPA that requires hospitals, doctors and health care providers to obtain. It consists of a 10 numeric digits for filing electronic claims with public and private insurances.
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  • Fall '19
  • Data element, V.S Stark II

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