An application for a claim.
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MEDICAL,USA: Document that is completed detailing the medical services rendered to a patient by the provider or facility and submitted to the insurance company for payment.
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MEDICAL,USA,REFERENCE: See: Health Insurance Claim Form (CMS-1500).
Tag: RAW
Claim fraud
Intentional misrepresentation by either providers or patients to obtain services, payment for services, or claim program eligibility. In insurance claims, fraudulent practices are intentionally double billing for the same services, reporting diagnoses and procedures to maximize payments, billing for services that were not performed, and so on.
Claim frequency rate
In health insurance calculations, this is a value obtained from the expected percentage of insured individuals who will file claims and the number of claims they will file within a specific period of time. This rate is used to calculate average claim costs, which are used to establish premium rates.
Claim investigation
Process of obtaining insurance claim information to decide if a claim should be paid by the insurance company.
Claim lag
1. Time period between the patient’s encounter (incurred) date of the insurance claim and its submission to the third-party payer. 2. Time period between the incurred date of the insurance claim and its payment by the third-party payer.
Claim list
Data evidence of claims paid under an insurance plan or coverage for a specific time period. Such lists include identification of the insured, cause of the insurance claim, description of service, and amount paid.
Claim Made Basis Liability Coverage
A Method of determining whether or not coverage is available for a specific claim. If a claim is made during the time period when a liability policy is in effect an insurance company is responsible for its payment, up the limits of the policy, regardless of when the even causing the claim occurred. Typically this type of coverage is endorsed with a prior acts date or retroactive date before which the insurance company has excluded coverage.
Claim manual
Administrative guidelines documented in a book used by insurance claims adjusters to settle (adjudicate) claims for payment according to the insurance company’s policies and procedures.
Claim number
Social Security number of the wage earner, which appears on the Medicare identification card.
Claim Payment, Ex-gratia
These are payment for losses which clearly fall outside the scope of the Policy. Although the losses are not payable, the Insurers, to avoid hardship to the insured, consider, in very special cases, settlement of these claims. For example, due to a genuine oversight a certain item of property may not be included in the Policy or renewal although in the past to was covered. These payments are made as an “act of grace” and are justifiable on grounds of good business Policy. Such settlements are never made on the basis of the full loss. A certain percentage only is paid. These payments are made “without prejudice,” that is to say, Insurers do not have an obligation to make similar payments in future.