Data that describe specific characteristics about a patient such as name, address, date of birth, sex, and Social Security number. These data are usually obtained when the patient is either admitted to the hospital or seen for the first visit in a physician’s office.

Type of community rating that takes into consideration several statistical characteristics (e.g., age, geographic area, industry, sex of the population).

Pertaining to statistical descriptions including distribution, density, and vital statistics of populations such as age, births, deaths, marital status, income, and unemployment.

Projects and contracts that Centers for Medicare and Medicaid Services (CMS) has signed with various health care organizations. These contracts allow CMS to test various or specific attributes such as payment methodologies, preventive care, and social care and to determine if such projects/pilots should be continued or expanded to meet the health care needs of the nation. Demonstrations are used to evaluate the effects and impact of various health care initiatives and the cost implications to the public.

Process of converting a stock insurance company to a mutual insurance company.
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The conversion of an insurance company from a mutual insurance company to a stock insurance company.

In the Medicare program, electronic and paper insurance claims may be rejected (formally denied) because the medical service was not covered, medical necessity was not met, the service was bundled with other services, the diagnosis was not covered, the claim was payable only in certain locations (e.g., outpatient only), prior approval was not obtained, or so on.

Alpha, numerical, or alphanumerical system used by insurance companies to explain partial or complete denials of insurance claims. Denial codes usually appear on documents such as explanation of benefits (EOBs).

1. Rejection of a medical service due to insurance coverage policy or insurance program issues. 2. Rejection of all or part of an insurance claim. Application of contractual copayments and deductibles is not considered a denial of a claim. 3. Official Medicare decision that services will not be approved for payment. This may be due to a decision that the service is not an approved service, not being provided in the proper setting for the level of care, not provided by an approved participating provider, or not medically necessary.

Medical claim submitted to an insurance company in which payment has been rejected due to a technical error or because of medical coverage policy issues. Also called denied paper claim or denied electronic claim .