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.

A type of foundation that provides peer review by physicians to the numerous fiscal agents or carriers involved in its area.

Description that names several people as a group instead of naming each person individually (e.g., children of the insured).

Method that provides the basis for payment that identifies medical services that will be charged fees separately (e.g., diagnosis-related groups [DRGs] patient classification system used for inpatient hospital prospective payment system, Healthcare Common Procedure Coding System [HCPCS] used in the Medicare fee schedule for physicians).

Type of hospital invoice (patient’s financial accounting statement) assessed by someone auditing a hospital bill that has no errors. Also see under bill and over bill.

Completed insurance claim form submitted within the program time limit that contains all the necessary information without deficiencies so that it can be processed and paid promptly; a claim that passes all electronic claim edits and claim audits; or a claim that is subject to medical review but is submitted with complete data attached or forwarded simultaneously with electronic media claim records.

Lump-sum type of life insurance death benefit to assist in paying the insured’s outstanding debts, funeral expenses, and related expenses—in other words, “cash” to clean up expenses.