Acronym that translates as payer identification number. The current acronym is NPLANID (national plan identifier). Medicare patients that have a Medigap supplemental insurance plan must show the PAYERID number (often called the OCNA [Other Carrier Name and Address] key ) in Block 9d of the CMS-1500 insurance claim form. The Medicare fiscal intermediary transmits a Medigap claim electronically to the Medigap carrier after processing it for participating physicians. This is called a crossover claim. See NPLANID.

1. Costs incurred for processing of data. 2. See reimbursement. 3. In Medicare fraud, deliberately applying for duplicate payment (e.g., to bill both Medicare and the beneficiary for the same service or to bill both Medicare and another insurance company to attempt to get paid twice). 4. Under the Health Insurance Portability and Accountability Act (HIPAA), use and disclosure of protected health information (PHI) is permissible for treatment, payment, and health care operations (TPO).

Collecting the amount or balance due directly from the patient at the conclusion of the patient’s office visit.

Program to assist in the reduction of Medicare prospective payment system (PPS) inpatient hospital reimbursement mistakes.

Minimum number of days that must pass before a Medicare administrative contractor can pay an insurance claim. Payment for manual claims is within 4 to 12 weeks and as little as 7 days when transmitted electronically. Prompt payment guidelines for clean claims transmitted by participating providers may be paid faster than for those submitted by nonparticipating providers.

Under Medicare guidelines, the amount that the provider must accept because of a contract or amount the provider voluntarily accepts as reimbursement in full from the insurer, meaning the patient’s obligation has been met.

One of the many geographical pricing areas used by Medicare administrative contractors (MACs) to calculate physicians’ customary and prevailing charges for payment. Localities are the basis for fee schedule payment areas and geographic adjustment factor (GAF) adjustments under the Medicare fee schedule (MFS).

System wherein the insured pays insurance premiums either monthly, quarterly, semiannually, or annually.

1. Dollar amount to be paid to a provider for medical services given to a member of a managed care plan. 2. Total payment that a hospital or community mental health center gets when it provides outpatient services to Medicare patients. Also see average payment rate (APR).

Activities to prevent and recover inappropriate Medicare benefit payments including Medicare Secondary Payer (MSP), medical review/utilization review (MR/UR), provider audits, and fraud and abuse detection.