Processing of an insurance claim by an insurance company through a series of edits for determination of coverage (benefits) and issue of payment to the provider or patient.

CPT codes that are referred to in the Medicine Section as Special Services, Procedures and Reports and fall under the category of Miscellaneous Services. They are important to consider when billing because these codes provide the reporting physician with a means of identifying special services and reports that are provided in addition to the basic services provided such as handling of laboratory specimens, telephone calls, seeing patients after hours, office emergency services, supplies and materials, special reports, travel, and educational services rendered to patients.

This type of dental care includes dental and oral tissue examination and diagnosis at the request of a physician (MD). It is provided after the physician’s examination and is done to help improve the systemic condition of the whole body and not just one area.

Life insurance contract that allows the policy owner to change the policy’s plan by changing the amount of the coverage or premium. The insurance company calculates the plan of insurance based on the chosen death benefit and premium. An adjustable life insurance policy can use a plan that ranges from a term insurance policy of short duration to a limited-payment whole life insurance policy.

Estimated average cost of Medicare benefits in a given region for an individual. It is based on criteria such as age, sex, institutional status, Medicaid, disability, and end-stage renal disease (ESRD) status. Centers for Medicare and Medicaid Services (CMS) uses AAPCC as a basis for making monthly payments to managed care plans.

System developed by Johns Hopkins University that is a comprehensive family of measurement tools designed to help explain and predict how health care resources are delivered and consumed. ACGs are based on building blocks called aggregated diagnosis groups (ADGs). See aggregated diagnosis groups (ADGs).

Annual calculation of premium (payment rates) that health plans would have received for their Medicare enrollees to provide Medicare-covered benefits if paid their private market premiums. This is done to adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. Also called average community rate (ACR). See adjusted average per capita cost (AAPCC).

Used by managed care plans to determine group rates for each group’s expected use of medical services during an upcoming contract period. Also known as factored rating or community rating by class (CRC).

Schedule showing names of a small amount of drugs often prescribed to long-term patients that can be modified from time to time by the managed care or insurance plan. Also called a drug maintenance list.

1. Accounts receivable amount showing the write-off portion from the total gross charges of amounts that by law or provider contract cannot be collected. 2. Medicare approved amount is the adjusted gross charge.