Computer software that allows Medi-Cal providers to electronically verify recipient eligibility, clear share of cost liability, reserve Medi-Services, perform Family PACT (planning, access, care, treatment) client eligibility transactions, and submit pharmacy or CMS-1500 claims using a personal computer.

Practitioner who works for the consumer and helps patients organize, complete, file, and negotiate health insurance claims of all types to obtain maximum benefits, as well as tell patients what checks to write to providers to eliminate overpayment.

1. In industrial cases, a representative of the insurer who investigates, evaluates, and negotiates the patient’s insurance claim and acts for the company in the settlement of claims. 2. Individual employed by an insurance company who assists in settlement of claims by investigating claims, approving claims that are valid, and denying claims that are invalid or fraudulent. Some claims examiners are individuals who operate independently and are hired by insurance companies to adjust a specific loss. Also called adjuster, claims processor, claims representative, claims administrator, or health insurance adjuster.

A Medi-Cal form used for tracing a claim, resubmitting a claim after a denial, or when requesting an adjustment for underpaid or overpaid claims.

Insurance company’s reimbursement director or executive administrator who supervises and oversees employees who process insurance claims for payment.

Audit by a peer review organization, insurance company, or other group of insurance claims submitted by a provider to validate payment or nonpayment, eligibility, or establish medical necessity of care and appropriateness of services provided.

Insurance company’s reimbursement employee who analyzes insurance claims similar to an auditor who checks procedure and diagnostic codes, prior authorizations, insurance contract violations, and so on.