Information that is collected, processed, and stored in automated information systems. Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.

In workers’ compensation insurance, the head of the Division of Workers’ Compensation.

Operating costs incurred by the Department of Health and Human Services (HHS) and the Department of the Treasury in administering the supplemental medical insurance (SMI) program and the provisions of the Internal Revenue Code relating to the collection of contributions. Such administrative expenses, which are paid from the SMI trust fund, include expenditures for contractors to determine costs of, and make payments to, providers, as well as salaries and expenses of Centers for Medicare and Medicaid Services (CMS).

Health insurance plan document that gives detailed explanations of the plan’s benefits, how to file insurance claims, payment of claims, deductibles, prescription drug plan, coordination of benefits, administrative rules, and so on.

Hearings officer who presides at a Level 4 hearing between providers of services, or beneficiaries, and Medicare contractors. Such situations occur when there is an appeal of a denied Medicare insurance claim, as well as appeals from proposed Office of the Inspector General (OIG) exclusions.

Reference book of instructions given to the insurance policyholder by the insurance company that explains the duties of the plan administrator.

Person who, under the direction of a physician, performs various routine front office tasks in a hospital, clinic, or other health facility. These duties may consist of scheduling patients for appointments, answering the telephone, interviewing and registering the patient, filing documents, billing, completing insurance claims, bookkeeping, and so on. Also see clinical medical assistant.

Contract between a self-funded insurance plan and an insurance company or third-party administrator (TPA) whereby the insurance company provides administrative services only and assumes no risk. Usually, this is an employer’s group health insurance program and it retains financial responsibility for payment of the insurance claims. Services include actuarial activities, benefit plan design, claim processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, preparation of data for federal reports, and stop-loss coverage. Also known as ACS contract.
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Contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, in which the insurer provides certain administrative services. These services may include actuarial support, plan design, claims processing, data recovery and analysis, benefits communications, financial advice, medical care conversions, data preparation for governmental reports, and stop-loss coverage.