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 .

Evaluation of information on an insurance claim or other information requested to support the medical services billed and to make a determination regarding payment to the provider.

Inventory of body systems obtained through a series of questions that is used to identify signs and/or symptoms that the patient might be experiencing or has experienced. ROS may clarify the differential diagnosis or identify needed tests. A documented report of the body system directly related to the problem must be identified in the history of present illness (HPI) plus all additional body systems (at least 10) for comprehensive assessments. Also called system review .

Acronym that means recipient eligibility verification system. See Medicaid eligibility verification system (MEVS) .