Approval number given to a provider who requests a specific service, treatment, test, or procedure. It does not guarantee payment if the insurance claim does not establish medical necessity and appropriateness of the care requested for a patient.

1. Individual who is a direct owner of 5% or more of a provider (e.g., business partner, chairman of the board, chief financial officer, chief executive officer, president). 2. Person to whom the provider gives legal authority to be enrolled in the Medicare program. The authorized official can make changes or updates to the provider’s status in the Medicare program and signs a statement that the provider will abide by the laws and regulations of Medicare.

Physician, other individual authorized provider of care, hospital, or supplier who meets the licensing and certification requirements, practices within the scope of that license, and is approved by TRICARE to provide medical care and supplies.

Type of treatment for cancer in which the patient is his or her own bone marrow donor as compared with allogenic bone marrow transplant in which the donor is another individual.

Claim evaluation and determination made using system logic (edits). Automated claim reviews never require the intervention of a human to make a claim determination.

Computerized claims processing system used in reimbursement of medical, dental, or disability insurance claims.

Third-party administrator (TPA) that receives information from another entity, performs software edits, and redistributes the claims electronically to various insurance carriers in a standard transaction. Also known as clearinghouse .

An interactive voice response system in the Medi-Cal program that allows providers to access recipient eligibility, clear share of cost, and/or reserve a Medi-Service.

Name of an insurance claim reimbursement method that uses computer technology in settling Medicaid claims.