Policies, procedures, and management of functions related to the operation of an insurance plan by the insurance company after it becomes effective. In some situations, the insurance claims processing and payment may be administered by a separate entity.

Fee paid to an agent or administrator for overseeing and managing an insured’s policy that would normally be handled by the insurance company.

1. Code sets that characterize a general business situation, rather than a medical condition or service. 2. Under the Health Insurance Portability and Accountability Act (HIPAA), a phrase that refers to nonclinical or nonmedical code sets. Compare with medical code sets.

General phrase that refers to Medicare operating expenses (salaries, facilities, equipment, rent, utilities) and the federal share of the states’ expenditures for administration of the Medicaid program

Information that is collected, processed, and stored in automated information systems. Administrative data include enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facility services, professional services, prescription drug services, laboratory services, and so on.

In workers’ compensation insurance, the head of the Division of Workers’ Compensation.

Operating costs incurred by the Department of Health and Human Services (HHS) and the Department of the Treasury in administering the supplemental medical insurance (SMI) program and the provisions of the Internal Revenue Code relating to the collection of contributions. Such administrative expenses, which are paid from the SMI trust fund, include expenditures for contractors to determine costs of, and make payments to, providers, as well as salaries and expenses of Centers for Medicare and Medicaid Services (CMS).

Health insurance plan document that gives detailed explanations of the plan’s benefits, how to file insurance claims, payment of claims, deductibles, prescription drug plan, coordination of benefits, administrative rules, and so on.

Hearings officer who presides at a Level 4 hearing between providers of services, or beneficiaries, and Medicare contractors. Such situations occur when there is an appeal of a denied Medicare insurance claim, as well as appeals from proposed Office of the Inspector General (OIG) exclusions.