Business management systems and policies for reasonably documenting, monitoring, and correcting operational processes to prevent and detect waste and to ensure proper payment.

Highest insurance plan amounts paid for each benefit or illness. The insured pays the remainder of the costs incurred. The insurance policy may state the limits in dollar amounts or in number of days payable.

Branch of medicine concerned with the study of the physiologic and pathologic characteristics of the internal organs and the medical diagnosis and nonsurgical treatment of disorders of these organs. IM encompasses many subspecialties.

To give up a life insurance policy because the insured wants to purchase another insurance policy issued by the same insurance company.

Process by which information on employers and employees is provided by the IRS and SSA and analyzed by the Centers for Medicare and Medicaid Services for use in contacting employers concerning a possible period of Medicare Secondary Payer (MSP). This information is used to update the Medicare Common Working File (CWF).

Process of going over financial documents in the medical office before and after billing insurance carriers to determine documentation deficiencies or errors.

ICA was founded in 1909 to promote efficiency, effectiveness, and high standards of performance in claim administration by member companies; provide a forum for research, education, and the exchange of ideas relating to various aspects of claim administration; and devise and effect measures for the benefit of policyholders and beneficiaries in matters relating to claims. ICA has been at the forefront of addressing a broad range of life, health, and disability claim issues including those relevant in the day-to-day operation of claim departments. The ICA provides a forum for information exchange and a program of education tailored to the needs of its member life and health insurance companies, reinsurers, managed care companies, TPAs, and Blue Cross and Blue Shield organizations worldwide.

Medical code set developed and maintained by the World Health Organization (WHO) primarily to classify causes of death. Eventually this code set became the standardized system of codes for diagnoses used to submit insurance claims for reimbursement to insurance carriers and for use in Health Insurance Portability and Accountability Act transactions.

Diagnostic code book that uses primarily a numeric code system for classifying diseases and operations to assist collection of uniform and comparable health information. These codes are used by physicians and inpatient and outpatient facilities to effectively document the medical condition, symptom, or complaint of each patient when submitting insurance claims to insurance companies for payment. Its conventions include special terms, punctuation marks, abbreviations, or symbols to communicate special instructions to the coder. If the conventions are overlooked, the code number chosen may be incorrect. A code system to replace this is ICD-10, which has an implementation date set for October 1, 2013.