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- ANSI X12 835:
- Stands for the American National Standards Institute Health Data Committee X12 file format 835. Hospitals receive healthcare claim payment & Remittance Advice transactions in the 835 format. This transaction has been included in the HIPAA mandates.
- ANSI X12 837:
- The 837 is the standard health care claim or encounter transaction format for EDI. Hospitals use the 837 format for healthcare claims submission to Medicare and other payors. The 837 transaction can be used for institutional, professional, dental, or drug claims. This transaction has been included in the HIPAA mandates.
- ABN:
- An Advance Beneficiary Notice of Noncoverage (ABN) is a notice that a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment. When a patient signs an ABN before the services are rendered, the patient assumes responsibility for paying for the service.
- Carrier:
- A private company that has a contract with Medicare to pay Medicare Part B bills.
- CMS:
- The Centers for Medicare and Medicaid Services (CMS) is the federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.
- FI:
- A Fiscal Intermediary (FI) is a private company that has a contract with Medicare to pay Part A and some Part B bills.
- HCPCS:
- The Healthcare Common Procedure Coding System (HCPCS) is a medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions.
- HIPAA:
- Health Insurance Portability & Accountability Act of 1996 (HIPAA).
- ICD-9:
- The International Classification of Diseases 9th Edition (ICD-9) is a medical code set maintained by the World Health Organization (WHO). The primary purpose of this code set was to classify causes of death. A US extension, maintained by the NCHS within the CDC, identifies morbidity factors, or diagnoses. The ICD-9 codes have been selected for use in the HIPAA transactions.
- LCD:
- A Local Coverage Determination (LCD) is a guideline to the local, state-by-state decisions by a Fiscal Intermediary (FI) or Carrier to cover a particular service. The LCD is also an administrative and educational tool to assist providers, physicians and suppliers in submitting correct claims for payment. Often an LCD will contain lists of CPT codes and their corresponding ICD-9 codes that support medical necessity.
- LMRP:
- Local Medical Review Policies (LMRPs) were phased out by CMS at the end of 2003. The LCD has replaced the LMRP, the only difference between the two being that LMRPs may contain category or statutory provisions while LCDs only contain "reasonable and necessary" information.
- NCD:
- A National Coverage Determination (NCD) is a guideline to the national decisions by CMS to cover a particular service. An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LCD).
- PHI:
- Personal Health Information (PHI) is individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. PHI identifies individuals or offers a reasonable basis for identification, is created or received by a covered entity or an employer, and relates to a past, present, or future physical or mental condition, provision of health care or payment for health care.
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