The process of arriving at an amount of settlement for a claim. It may consist of a series of computations to arrive at the amount of a loss, as in a complicated fire loss. It may involve discussions of liability, quantum, and other such matters as might be the case in a problem liability claim. It may contain both.
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MEDICAL, US:
1. Posting an entry to a patient’s financial account to indicate a change to the balance due such as additional payment, partial payment, courtesy adjustment, write off, discount. 2. Change made to correct an error in billing, processing of a claim, or as a result of a retroactive rate change (e.g., late charges for a previously submitted bill). These situations may be found by either claims personnel or by the provider. Possible errors that would allow adjustments to be processed include overpayment, underpayment, or payments to the wrong provider.
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The process of dealing with a claim starting with its investigation and concluding with its settlement or disposal. The work can be carried out by the insurer’s own claims staff or by a loss adjuster.
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The process of determining the cause and amount of a loss, the amount of indemnity the amount of indemnity the insured may recover after all proper allowances and deductions have been made, and the proportions that each Company is required to pay under its contract if there is more than one Insurance Company involved.
An organization that contracts with insurers to provide loss settlement services on behalf of those insurers.
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Organization for adjusting insurance claims that is supported by insurers using the bureau’s services.
Special codes used by insurance carriers to explain the reason an insurance claim or a medical service was paid differently than the billed amount.
A benefit that provides an income to a beneficiary once the primary wage earner has died. This income is intended to help cover expenses until the beneficiary is self sufficient.
An additional premium payable under the terms of the contract as a result of claims experienced under a policy of insurance or reinsurance.
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An additional or return premium that is payable in relation to a deposit premium depending on the performance of an insurance or reinsurance contract.
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The adjustment premium is a further premium payable at the end of a period of cover. This may result from the use of retrospective experience rating or from a situation where the exposure cannot be adequately determined at the start of the period of cover.
A stipulation in a policy that permits changes to the policy, which are then executed by increasing or decreasing the premium or face amount. Also can be changed by extending or decreasing the duration of protection or premiums.
Reference list of coded explanations of changes made to a paid insurance claim. The codes detail and clarify all services reported and eliminate having to generate a separate letter of explanation.
Changes or modifications to the base payment rates to allow for differences in providers’ situations that affect their costs of giving medical services. These adjustments are to accommodate differences in local prices for products and services, delivery of specialized types of care, or atypical characteristics of beneficiaries.
Additional technique(s) that may be required at the time a bypass graft is created to improve patency of the lower extremity autogenous or synthetic bypass graft or fistula. Use of CPT codes 35685 and 35686 are add-on codes and should be reported with a code for the primary procedure performed.
Policies, procedures, and management of functions related to the operation of an insurance plan by the insurance company after it becomes effective. In some situations, the insurance claims processing and payment may be administered by a separate entity.