Automated voice-response system that allows the provider to use the telephone to obtain checkwrite, claim, and prior authorization information for services rendered through the Medi-Cal program and several other state programs.

Method that identifies providers and follows all contacts made to correct problems (e.g., provider’s eligibility, medical necessity issue, repeat billing abusers).

Formerly known as provider identification number (PIN). It is a carrier-assigned number that every facility, physician, clinic, or organization uses that renders services to patients when submitting insurance claims. It is issued to a provider by the insurance carrier or Medicare fiscal intermediary and allows the physician or patient to receive reimbursement for claims filed to the contractor. Also referred to as a legacy number. PINs have been replaced with the national provider identifiers (NPIs). See national provider identifier (NPI).

Group of doctors, hospitals, and other health care providers that agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. This type of managed care plan is run by the doctors and providers themselves and not by an insurance company. Also called provider health plan or provider-sponsored network (PSN).

Manual claim information inserted in the bottom half of the CMS-1500 (08-05) claim form.

Premium requested by an insurance company for a type of policy that needs a premium adjustment. For example, a commercial property or liability insurance policy’s final premium is determined at the end of the policy period based on an insured’s loss experience and other factors.
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UK: The premium charged under an adjustable policy at the inception.

Temporary or conditional rights that a physician is given at a medical facility for a specific length of time during which supervisors assess and validate his or her clinical performance.

MEDICAL,USA: Legal term dealing with the concept of cause-and-effect relationships (e.g., would an injury have resulted from a particular accident?).
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That event that, in an unbroken sequence, results in direct physical loss under an insurance policy. For example, wind is the proximate cause of loss when a windstorm blows out a window that in turn topples a lit candle that sets fire to a structure and burns it down.
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US: The dominating cause of loss or damage; an unbroken chain of events between the occurrence and damage.
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The immediate or actual cause of loss under an insurance policy. See Also: “Cause, Proximate.”
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UK: The insurer is liable only for loss proximately caused by an insured peril not loss caused by an excepted or uninsured peril. It is the dominant cause not the remote cause. The insurer will be liable if the sequence between an insured peril and the loss is unbroken (i.e one link in the chain is the natural and probable consequence of the previous link). If the initial cause in an unbroken chain is an excepted peril, the excepted peril is the proximate cause notwithstanding that it triggers an insured peril. As well as operating sequentially with other perils, the insured peril may run as a concurrent cause with other perils. Pawsey v. Scottish Union and National (1907) sets out a classic definition. See IMMEDIATE CAUSE; INTERVENING CAUSE; LAW STRAW CASES.