Evaluation of insurance claims for duplicate medical services or billing that may be in excess of a normal pattern.

Unique multidigit number assigned by the Medi-Cal fiscal intermediary on a Treatment Authorization Request and used for reference when processing the request.

Insurance company’s attempt to streamline operations to contain and direct claim payments so that insurance premium funds are used efficiently.

Electronic examination of transmitted insurance claims for errors, conflicting code entries, and a match of diagnosis to medical service(s) provided. Also called edit check. See front-end edits.

Accumulation of information needed for payment or denial of an insurance claim.

Intentional misrepresentation by either providers or patients to obtain services, payment for services, or claim program eligibility. In insurance claims, fraudulent practices are intentionally double billing for the same services, reporting diagnoses and procedures to maximize payments, billing for services that were not performed, and so on.

In health insurance calculations, this is a value obtained from the expected percentage of insured individuals who will file claims and the number of claims they will file within a specific period of time. This rate is used to calculate average claim costs, which are used to establish premium rates.

Process of obtaining insurance claim information to decide if a claim should be paid by the insurance company.

1. Time period between the patient’s encounter (incurred) date of the insurance claim and its submission to the third-party payer. 2. Time period between the incurred date of the insurance claim and its payment by the third-party payer.

Data evidence of claims paid under an insurance plan or coverage for a specific time period. Such lists include identification of the insured, cause of the insurance claim, description of service, and amount paid.