Form that, when completed, provides the insurance company with information about the patient’s injury or illness, diagnosis, and treatment. An APS form is completed when the insurance company requests information to decide whether to insure an individual or, if insured, when settling an insurance claim.

Disenrollment from a health insurance plan expressed as a percentage of total membership. For example, a managed care plan with 40,000 members with a 2% attrition rate would need to gain 800 new members each month to retain the initial 40,000 covered lives.

1. Formal, methodical examination or review done to inspect, analyze, and scrutinize the way something is being done (e.g., bookkeeping practices, medical record documentation, insurance claim filing) to determine operational efficiency. 2. In the Medicare program, a process to ensure that the fiscal intermediary reimburses providers based only on costs associated with patient care.

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Some policies (such as workers compensation) are written subject to an audit. Since workers compensation premium is based on the insured’s payroll, the insurer is entitled to audit the insured’s records at the end of the policy to verify that it has collected an adequate premium for the amount of payroll to which it was exposed.

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US: A survey of the financial records of a person or organization conducted annually (in most cases) to determine exposures, limits, premiums, etc.

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Survey of an insured’s records to determine the premium which should be paid to the Insurer for protection furnished and perhaps for other purposes, such as compliance with loss control recommendations.

Type of audit of hospital patient records that occurs when a patient asks for an audit to verify hospital charges. Also see defense audit and random internal audit.

Add to or increase a body site (e.g., plastic reconstruction procedure, implant, prosthesis, bone or soft tissue graft).

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UK: Provision of additional benefits for particular members of an occupational pension scheme. The cost normally falls on the employer.

1. Verify authorship of a patient’s medical record by signature, initials, or rubber stamp that data are accurate, complete, and final. 2. Verify or identify access privileges of a user or user device to an information system. 3. Process to certify that a document is genuine.

Method of type of approval that requires a determination that the service is likely to have a diagnostic or therapeutic benefit for patients for whom it is intended.

Written medical or scientific conclusions demonstrating the medical effectiveness of a service produced by the following: controlled clinical trials, published in peer-reviewed medical or scientific journals; controlled clinical trials completed and accepted for publication in peer-reviewed medical or scientific journals; assessments initiated by the Centers for Medicare and Medicaid Services (CMS); evaluations or studies initiated by Medicare contractors; case studies published in peer-reviewed medical or scientific journals that present treatment protocols.