1. In the Medicare program, after payment or denial of an insurance claim, this is the second level of appeal. 2. First level of appeal process for an individual applying for SSDI or SSI. It is a complete review of the claim by a medical or psychological consultant/disability examiner team who did not take part in the original disability determination.

Plastic surgery performed to improve physical function and lessen disfigurement from an accident or injury, birth defect, burn, or disease. Difference between reconstructive surgery and cosmetic surgery is that the latter is considered elective and done for aesthetic reasons. See cosmetic surgery .

Keeping medical records based on state and/or federal statutes. The federal minimum for records retention is at least 6 years after the patient is last seen. Each state has different laws but usually mandate longer than 6 years. State law has more authority than federal statutes. The American Health Information Management Association (AHIMA) recommends retaining medical records for 10 years after the date the patient was last seen regardless of whether the state regulation says 7 to 10 years. Records of children must be kept a certain amount of time after the patient becomes an adult, which can be anywhere from age 18 to 21 depending on the state law.

Recovery by Medicare of any Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

Demonstration project developed from the Medicare Prescription Drug Improvement and Modernization Act. States that participated in this project for three years (2006-2008) have been California, Florida, and New York.

Monies obtained from a successful judgment, settlement, erroneous, or conditional payment. Also called recovery of money .

In workers’ compensation cases, refers to symptoms that occur or may have been expected to occur of a previous industrial injury or illness without relationship to the current employment. This would not constitute a new injury.

Provision in an insurance policy that details the benefits payable if an insured becomes disabled again by the same illness or condition when benefits previously were paid.