Under the Health Insurance Portability and Accountability Act (HIPAA), a third-party administrator (TPA) who receives insurance claims from the physician’s office in a nonstandard format or with nonstandard data and puts it into standard data elements or a standard transaction, or that receives a standard transaction and processes or assists processing the data into nonstandard format for a receiving entity. The TPA performs software edits and redistributes the claims electronically to various insurance carriers.

Unified body of health care providers, purchasers of care, industry, labor, and insurance companies to try to solve medical costs and problems.

Working group of individuals administered by the Blue Cross and Blue Shield Association. It is responsible for maintaining specific coding schemes used in the X12 transaction set such as claim adjustment reason codes, claim status category codes, and claim status codes.

Provide health care services to those in a community.

Method of structure and coordination encompassing medical facilities, health care services, and reimbursement methods to provide health care.

Former name of the federal agency within the Department of Health and Human Services (DHHS) established to administer and oversee Medicare, Medicaid, and State Children’s Health Insurance Programs, as well as other governmental health programs. This agency is now called Centers for Medicare and Medicaid Services (CMS) . See Centers for Medicare and Medicaid Services (CMS) .

Health care professionals, generally registered nurses, who are located at TRICARE Service Centers to act as liaison between military and civilian providers, verify eligibility, determine availability of services, coordinate care, facilitate the transfer of records, and perform first level medical review. This health care specialist helps TRICARE beneficiaries and providers with preauthorizations of medical services.

Employer-sponsored benefit that allows a fixed amount of pretax wages to be set aside for qualified expenses such as child care or uncovered medical expenses. Money in these accounts cannot be rolled over from year to year.