Document with information, hard copy or electronic, related to a completed insurance claim that assists in validating the medical necessity or explains the medical service or procedure (e.g., operative report, discharge summary, invoice). When a claim attachment is included with a paper claim, Block 19 of the CMA-1500 insurance claim form is completed. When a claim is electronically transmitted, practice management and claims software include a data field that indicates that a paper claims attachment is included with the claim. Under the Health Insurance Portability and Accountability Act (HIPAA), electronic standards for claims attachments are being developed. Attachments may be structured (such as Certificates of Medical Necessity) or nonstructured (such as an operative report). Though attachments may be submitted separately, it is common to say the attachment was “submitted with the claim.”
Tag: RAW
Claim audit
Evaluation of insurance claims for duplicate medical services or billing that may be in excess of a normal pattern.
Claim Cohort
A group of claims with a common period of origin. The period is usually a month or a quarter or a calendar year. The origin varies but is usually defined by the date of reporting, or by the date of payment of a claim.
Claim Control Clause
A clause in a Reinsurance contract requiring the Reinsured to give immediate advice to the Reinsurance of any claim that will attach to the Reinsurance contract before he settles it on the original Policy. The clause may require that the Reinsurer’s approval be obtained before the original claim is settled. The Reinsured will be expected to cooperate with the Reinsurer in defending the original claim at the Reinsurer’s option.
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Refer: “Reinsurance, Claims Control Clause”
claim control number (CCN)
Unique multidigit number assigned by the Medi-Cal fiscal intermediary on a Treatment Authorization Request and used for reference when processing the request.
Claim cost control
Insurance company’s attempt to streamline operations to contain and direct claim payments so that insurance premium funds are used efficiently.
Claim Cost Inflation
The rate of increase in the cost of claim payments. It is likely to be influenced by many different types of inflationary force, e.g., general or specific salary inflation, general or specific price inflation, court award inflation.
Claim department
The insurance company’s department that assesses whether claims will be paid.
Claim edits
Electronic examination of transmitted insurance claims for errors, conflicting code entries, and a match of diagnosis to medical service(s) provided. Also called edit check. See front-end edits.
Claim expense
The expense of adjusting a claim, such as investigation and attorneys’ fees. It does not include the cost of the claim itself.
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The costs, other than the actual claim cost, that are associated with paying a claim.