Federal and state statutes that prohibit institutional mergers and acquisitions, exclusive contracts, joint ventures, price discriminations, price fixing, monopolies, and business dealings in situations that may greatly reduce competition, which may lead to a detrimental effect on consumer welfare. In medical care, this concerns arrangements between specialists that render exclusive service contracts with their hospitals. The main federal antitrust acts are: Sherman Antitrust Act (1890), Clayton Act (1914), Federal Trade Commission Act (1914), and Robinson-Patman Act (1936).

Multiple state laws that establish policies for managed care agreements that require a provider network must enroll any provider who meets the network’s plan provisions.

1. See anteroposterior (AP). 2. HCPCS Level II modifier that may be used with CPT or HCPCS Level II codes indicating there was no determination of refractive state during an eye examination. Use of this modifier does not affect payment.

1. Request for a review of an insurance claim that has been underpaid or denied by an insurance company to receive additional payment. Such requests are made to the health plan by the patient who is represented by the physician or provider who submitted the original insurance claim. Appeals to self-insured plans are submitted to the employer or U.S. Department of Labor. In some cases, an appeal may be submitted to the Department of Insurance of the state where the plan is located. 2. Redetermination process whereby the provider and/or beneficiary (or representative) exercises the right to request a review of a contractor’s decision to deny Medicare coverage or payment for a service in full or in part. Also called postservice appeals. See also preservice appeal and expedited appeal.

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The right of a party who has received an adverse decision to take the case to a higher court for review.

In the Medicare program, a course of action used by a patient (beneficiary) if he or she disagrees with any decision about the health care services received. Now referred to as redetermination process.

1. Request process to reconsider a decision by an insurance plan after a first appeal. 2. In the Medicare program, the first step for an appeal is called redetermination (telephone, letter, or CMS-20027 Form) and the second step after a first appeal is called reconsideration.

Right of an individual or provider to ask for a review of the case for a possible change in the decision.

In workers’ compensation cases, this phrase refers to the Workers’ Compensation Appeals Board (WCAB) of the Division of Workers’ Compensation in each state.

Individual who appeals a claim decision.

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The person making an appeal to the higher court.