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Appeal
Request made to a payor to reconsider a decision, such
as a claim denial or denied prior authorization request. Most appeals must
be submitted in writing within a specified period.
Assignment of Benefits (AOB)
Instruction provided from an insured to a health plan,
advising that payment for an item provided or service rendered should
be sent directly to the provider of that item or service. In this scenario,
the provider is responsible for billing the health plan for the item
or service.
Benefit cap
Total dollar amount that a payor will reimburse for
covered medical services.
Claim
Form submitted to a payor (by a health care provider
or patient) to request payment for items or services provided.
Coding
The language used by providers and payors to communicate
services performed, products provided, and the medical need for each.
Coding provides universal definition and recognition of diagnoses,
procedures, products, and levels of care.
Co-insurance
Cost-sharing arrangement between an insured and insurer
in which the insured will be required to pay a percentage of the cost
for the health care services received (for example, 20% of the cost
of Kineret®).
Co-payment
Cost-sharing arrangement between an insured and insurer
in which the insured will be required to pay a specified dollar amount
for a particular item or service (for example, $20 for a 1-month
supply of Kineret®).
Current Procedural Terminology (CPT®)
A system of terminology and coding developed by the
American Medical Association (AMA) that is used for describing, coding,
and reporting specified medical services and procedures.
CPT® is a registered trademark of the American Medical Association (AMA).
Deductible
Cost-sharing arrangement between an insured and insurer
in which the insured will be required to pay a fixed dollar amount
of covered expenses each year before the payor will reimburse for covered
health care expenses. Generally, an insured must meet a deductible
each calendar year.
Explanation of Benefits (EOB)
Statement sent by payors to health care beneficiaries
that details the charges for the services received, the amount the
insurance company will pay for those services, and the amount the beneficiary
will be responsible for paying.
Formulary
Approved list of prescription medications covered by
a payor. Depending on the individual plan, an insured may have an "open
formulary," which would allow access to nonformulary medications
at a higher cost, or a "closed formulary," which would require
that the insured access only those medications included on the health
plan's formulary.
Grievance
Request made to a payor to reconsider coverage of a
health care service that is not currently a covered benefit.
HCFA Common Procedure Coding System (HCPCS)
Name given to CPT codes (Level I), alphanumeric codes
(Level II), and local codes (Level III) used by payors and providers
for billing purposes. Within the industry, most refer to Level II national
codes as HCPCS codes.
International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM)
Coding system maintained by the National Center for
Health Statistics and the Center for Medicare and Medicaid Services (CMS).
This coding system differentiates diagnostic conditions and is used by
hospitals, governments, health insurance plans, and health care providers
around the world.
Kineret® Customer Call Center
A comprehensive support service that can support all
customer needs from patient questions to clinical questions
from the provider. Nurses are available to assist patients with questions
on self-injection training, and reimbursement counselors will help
patients and providers understand third-party coverage for Kineret®.
Call 1-866-KINERET (1-866-546-3738).
Kineret® Reimbursement Services
One arm of the Kineret® Customer Call Center; reimbursement counselors
are available to assist providers and patients in determining
patient's medical and pharmacy benefits to access
Kineret®. Reimbursement
counselors are deployed on a "case management" model, where
one counselor is responsible for the case from first
contact to closure. Kineret® Reimbursement
Services can be reached by way of the Kineret® Customer Call Center
at 1-866-KINERET (1-866-546-3738).
Medicaid
Federal and state health insurance program for low-income
individuals who meet established eligibility criteria (programs vary
from state to state).
Medical necessity
Medical information justifying that the service rendered
or item provided is reasonable and appropriate for the diagnosis or
treatment of a medical condition or illness.
Medicare
Federal health insurance program for the elderly (age
65 and older), certain disabled individuals, and those with end-stage
renal disease. Medicare is administered by the Center for Medicare
and Medicaid Services (CMS).
Medigap
Health plans offered by private insurance companies
to individuals with Medicare. Plans cover costs not typically covered
by Medicare (designed to "fill the gaps" of Medicare coverage).
Costs covered may include co-insurance amounts, deductibles, and prescription
drugs.
National Drug Code (NDC)
Numerical coding system for drug identification. NDC
numbers are assigned by the Food and Drug Administration (FDA) and
are typically used to bill payors for the drugs provided to health
care beneficiaries. The NDC number for Kineret® is 55513-177-28.
Out-of-pocket maximum
Total dollar amount an insured will be required to
pay for covered medical services during a specified period, such as
1 year. The out-of-pocket maximum may also be called the stop-loss
limit or catastrophic expense limit.
Preexisting condition
Medical condition for which an insured received medical
care prior to the health insurance coverage becoming effective. Depending
upon the plan's policy language, the payor may limit the amount of
care it will reimburse related to the preexisting condition.
Prior authorization
Review of need for health care items or services before
services are rendered or products are provided. This refers to a decision
made by the payor to cover or not cover the charges before the services
are provided.
Usual, customary, and reasonable charge
Prevailing charge for an item or service in a particular
geographic area.
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