Phrase used in describing two x-ray projections or views (front to back and side) in the radiological examination.

Medicare regulation that limits the amount that can be billed by a physician or group practice for the technical component of diagnostic tests (excluding clinical diagnostic tests performed by clinical laboratories) that are performed by an outside supplier.

Statute in most states that it is illegal practice by an insurance agent to discount or return any portion of his or her commission to encourage an applicant to buy or renew an insurance policy.

Laws that forbid a physician from referring a patient to receive a service or supply in which the referring physician has a financial relationship to the supplier. Also known as Stark I Regulations and Stark II Regulations.

Federal and state statutes that prohibit institutional mergers and acquisitions, exclusive contracts, joint ventures, price discriminations, price fixing, monopolies, and business dealings in situations that may greatly reduce competition, which may lead to a detrimental effect on consumer welfare. In medical care, this concerns arrangements between specialists that render exclusive service contracts with their hospitals. The main federal antitrust acts are: Sherman Antitrust Act (1890), Clayton Act (1914), Federal Trade Commission Act (1914), and Robinson-Patman Act (1936).

Multiple state laws that establish policies for managed care agreements that require a provider network must enroll any provider who meets the network’s plan provisions.

1. See anteroposterior (AP). 2. HCPCS Level II modifier that may be used with CPT or HCPCS Level II codes indicating there was no determination of refractive state during an eye examination. Use of this modifier does not affect payment.

1. Request for a review of an insurance claim that has been underpaid or denied by an insurance company to receive additional payment. Such requests are made to the health plan by the patient who is represented by the physician or provider who submitted the original insurance claim. Appeals to self-insured plans are submitted to the employer or U.S. Department of Labor. In some cases, an appeal may be submitted to the Department of Insurance of the state where the plan is located. 2. Redetermination process whereby the provider and/or beneficiary (or representative) exercises the right to request a review of a contractor’s decision to deny Medicare coverage or payment for a service in full or in part. Also called postservice appeals. See also preservice appeal and expedited appeal.

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The right of a party who has received an adverse decision to take the case to a higher court for review.