Reference book of instructions given to the insurance policyholder by the insurance company that explains the duties of the plan administrator.

Person who, under the direction of a physician, performs various routine front office tasks in a hospital, clinic, or other health facility. These duties may consist of scheduling patients for appointments, answering the telephone, interviewing and registering the patient, filing documents, billing, completing insurance claims, bookkeeping, and so on. Also see clinical medical assistant.

Contract between a self-funded insurance plan and an insurance company or third-party administrator (TPA) whereby the insurance company provides administrative services only and assumes no risk. Usually, this is an employer’s group health insurance program and it retains financial responsibility for payment of the insurance claims. Services include actuarial activities, benefit plan design, claim processing, data recovery and analysis, employee benefits communication, financial advice, medical care conversions, preparation of data for federal reports, and stop-loss coverage. Also known as ACS contract.
******
Contract between an insurer (or its subsidiary) and a group employer, eligible group, trustee, or other party, in which the insurer provides certain administrative services. These services may include actuarial support, plan design, claims processing, data recovery and analysis, benefits communications, financial advice, medical care conversions, data preparation for governmental reports, and stop-loss coverage.

Association that provides only administrative services for a self-funded insurance company or entity such as billing, practice management, and marketing.

Title II, Subtitle F, of HIPAA, which gives Health and Human Services (HHS) the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. This is also the name of Title II, Subtitle F, Part C of HIPAA.

Statute that was signed into law on December 27, 2001, as Public Law 107-105. It provides a 1-year extension to Health Insurance Portability and Accountability Act (HIPAA)–covered entities to meet electronic and code set transaction requirements. It allows the Secretary of the Department of Health and Human Services (HHS) to exclude providers from Medicare if they are not compliant with the HIPAA electronic and code set transaction requirements and to prohibit Medicare payment of paper claims received after October 16, 2003, except under certain situations.

Subpoenas issued in the course of administrative proceedings or investigations seeking the disclosure of medical records or other patient health information such as hearings before disciplinary boards to revoke professional licenses, proceedings before state agencies to determine the propriety of facility license citations, and disputes before administrative law judges about proper Medicare or Medicaid reimbursement.

Registration of a patient either as an inpatient or outpatient for receiving medical services in a health care facility. The patient is given a register number. An admission can be either a direct admission, a direct admission from the emergency department, or transfer-in from another medical facility. See also inpatient admission, outpatient admission, and newborn admission.

Daily hospital report that shows patients gained and lost in census, changes in status, and numerical strengths of transient patients and boarders.

Method of assuring that only those patients who need hospital care are admitted. Certification can be granted before admission (preadmission) or shortly after (concurrent). Length of stay for the patient’s diagnosed problem is usually assigned on admission under a certification program.