1. In external auditing, process of going over financial documents after billing an insurance carrier to determine documentation deficiencies and errors. Also called retrospective payment audit . 2. In utilization review, evaluation of medical services given to a patient to make sure the insurance claims are paid for appropriate care (i.e., medical necessity, quality of care, physicians’ practice patterns, hospitals’ average length of stay, and reasonableness of services given).

In reference to Centers for Medicare and Medicaid Services (CMS) data, a situation that occurs when a requestor from the same or different organization requests permission to use CMS data already obtained for a prior approved project.

Recognition of income earned and the use of appropriated capital from the rendering of services in the current period.

Four-digit number in the hospital’s chargemaster that identifies a specific accommodation, ancillary service, or billing calculation related to the claim being submitted. These payment codes are inserted in Field 42 in ascending order on the Uniform Bill (UB-04) inpatient hospital billing claim form. Billing guidelines for revenue codes are extensive, so refer to the UB-04 manual for detailed information. Revenue codes are important because some managed care plans base payment on diagnosis, procedure, and revenue codes. All revenue codes from 001 to 999 must be preceded with a “0.” The leading “0” is added automatically for electronic claims. Basic revenue codes end in “0.” Detailed revenue codes end in 1 through 9. Do not repeat revenue codes on the same claim except when required by field or for coding more than one HCPCS code for the same revenue code item.

Proportion of a medical practice’s total income allocated for a specific type of expense (e.g., practice expense profit share is that proportion of income used to pay for practice expense).

Payment method in which subspecialists are paid a capitated rate and primary care physicians are paid on a fee-for-service (FFS) basis. This is considered reverse because most managed care plans pay the primary care physician capitated payments and pay subspecialists on an FFS basis.

In a managed care plan, membership established in the name of a member, who was not previously the subscriber, who is given a new identification number.

1. Independent, critical examination of an insurance claim made by the insurance carrier personnel not involved in the initial claim determination. 2. Request for a redetermination to the local Medicare carrier by telephone or in writing. 3. Brief note or a provider’s initials appended to a test report is considered a review; when billing, it is included in evaluation and management services.

Group of individuals who evaluate insurance claims that have been denied payment by the insurance carrier and appealed by the provider of the medical services. In the Medicare program, this process is called redetermination and was formerly known as review .