Also spelled donut hole . Another name for the step in a Medicare Part D plan in which the patient pays all of the expenses for eligible drugs until he or she has spent $3850. Also referred to as coverage gap or The gap .

Period during which a computer, communications line, or other device is malfunctioning or not operating correctly because of mechanical or electronic problems.

Reduce the value and procedure code of an insurance claim when the documentation supports a higher level of service billed by a provider.

1. Coding system used by the physician’s office does not match the coding system used by the insurance company receiving the claim. The insurance company computer system converts the procedure code submitted to the closest code in use, which is usually down one level from the submitted code, generating decreased payment. Sometimes downcoding may occur when the diagnosis code does not support the level of care. 2. Selecting procedure codes at a lower level than the medical service requires or documentation supports. Also called undercoding . Also see penalized claim.

To transmit or receive a data or graphic file from one computer to another.

To apply the correct commission scale to the insurance premiums received in order to compute the commissions due.

Type of insurance claim adjudication (settlement) in which the insurance company authorizes the policyholder (insured) to settle claims and to issue payment on behalf of the insurer.

Archaic term for any X12 standard that has been approved since the most recent release of X12 American National Standards. The current equivalent term is X12 standard.