Glossary (A-C)

What is ABN(Advance Beneficiary Notice) (Waiver of Liability)

A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Assignment of insurance benefits

An authorization granted by the patient to allow the insurance company to pay claim benefits directly to the provider of care. It is to the provider's benefit to have the patient sign the "assignment of benefits" statement on each claim form. All benefits due to the provider will be mailed directly to the provider rather than to the patient.

Attending physician

The physician in charge of the patient's care; this physician may or may not be the physician who admitted the patient to the hospital.

Capitation

A reimbursement system used by HMOs and some other managed care plans to pay the health care provider a fixed fee on a per capita basis that has no relationship to type of services performed or the number of services each patient receives.

Catastrophic Limit

For services with co-payments or coinsurance, this is the maximum amount out-of-pocket charges you have to pay in a calendar year. Separate limits are usually applied on a per person and per family basis.

Clearing House

It is also referred to as Third Party Administration (TPA). It is an entity that receives, sorts, transmit, edit claims and send each one to correct insurance payer.

Coordination of benefits (COB)

A clause written into an insurance policy or stipulated by state law that requires insurance companies to coordinate the reimbursement of benefits when a policyholder has two or more medical insurance policies. The benefits from the combined policies may pay up to, but may not exceed, 100 percent of the covered benefits of the combined policies for all medical expenses submitted.

Crossover

Medigap crossovers occur only if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating Medicare provider.

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