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).