Terminology

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Across
  1. 2. the answer that the reviewer provided on the case
  2. 3. laws and rules established by individual state governments to oversee and manage the insurance industry within their jurisdiction.
  3. 5. a formal assessment or examination of the client’s submitted request with the possibility or intention of instituting change if necessary.
  4. 6. or experimental and investigational refers to treatments, procedures, or services that are not widely accepted as standard practice by the medical community.
  5. 8. defines the terms, conditions, and coverage details of a policy, including critical, often confusing, jargon regarding costs and services.
  6. 9. phone call attempts from a reviewer to a patient’s doctor to discuss details of the case and to gather additional information that may not have been submitted initially.
  7. 13. a physician or specialist who is treating the patient and recommending the service that is requested in the cases.
  8. 15. an internal identifier as to which client and line of business the case is for.
  9. 19. a review of the same information or additional information completed by a reviewer who has not previously reviewed the case.
  10. 21. or SSL, used for state specific cases to add a second license to satisfy state regulations.
  11. 25. or Clarification of Completed Review is a re-do of a case that was previously submitted to the client to address any issues found.
  12. 26. a timeframe that the client gives us to complete the review.
  13. 27. a request made to an insurance company for payment based on the terms of the policy.
  14. 31. a medical professional who is part of the clinical staff that are not a licensed medical doctor, can be a physical therapist, occupational therapist, speech therapist, chiropractor, podiatrist, acupuncturist, or a dentist.
  15. 34. the specific protection provided by an insurance policy against certain risks of losses.
  16. 35. receives the case from the reviewer to further process the case to analyze and ensure all client-specific requirements are met within the review, and formatted with good grammar and punctuation.
  17. 36. the team that receives the case from the client, puts it together, and sends it to a reviewer.
  18. 37. a single case is sent out to multiple reviewers.
  19. 38. or Standard Of Care refers to the level and type of care that a reasonably competent and skilled healthcare professional, with a similar background and in the same medical community, would provide under similar circumstances.
  20. 39. PDF created when a completed case is submitted back to the client.
  21. 40. documenting all communication and decisions regarding the case including phone call and/or special instructions for the case.
  22. 45. services or procedures that are reviewed after they have been performed.
  23. 46. also known as a case number, is an identifying number that is assigned to each case that is submitted to MRIoA.
  24. 48. feedback provided for quality and/or coaching of a reviewer on a specific case.
  25. 49. or United States Food and Drug Administration protects public health by regulating human and veterinary drugs, vaccines, biological products, medical devices, the nation’s food supply, cosmetics, dietary supplements, and tobacco products.
  26. 50. a Microsoft Word document that is automatically created and used between the analyst, the Medical Team, and auditors for editing purposes of the review.
  27. 51. or Current Procedural Terminology code is a code used by healthcare providers to describe medical, surgical, and diagnostic services.
  28. 52. an integrated submittal form that the client fills out with all applicable information and request that is for the case itself.
Down
  1. 1. inquiries and concerns from the client about a case that is being worked or has been returned.
  2. 4. run by the government, not overseen by a specific state.
  3. 7. is a process that uses case notes to put a case in a holding place while waiting on direction from a client or supervisor.
  4. 9. services or procedures that require approval from the insurance company before they are performed.
  5. 10. created when the reviewer sends the case back to MRIoA for the completion steps.
  6. 11. or Healthcare Common Procedure Coding System, a standardized coding system used to facilitate the processing of healthcare claims.
  7. 12. a review for the same patient and client request sent to two or more reviewers.
  8. 14. or The National Committee for Quality Assurance is an accreditation company known for its Healthcare Effectiveness Data and Information Set (HEDIS), which is used by more than 90% of America's health plans to measure performance on important dimensions of care and service.
  9. 16. a set of guidelines for coverage decisions on a specific service.
  10. 17. a program is used by both the Health and Pharmacy departments. Star is the program we will use to process cases.
  11. 18. a process when a case that has already been assigned to a reviewer would need to be reassigned to a second reviewer to finish.
  12. 19. or addendum is when additional edits or corrections is made on a case that was submitted to the client.
  13. 20. or PHI, refers to any information about health status, provision of health care, or payment for health care that can be linked to a specific individual.
  14. 22. a statement that is added to the review that addresses the determination at a sixth grade reading level.
  15. 23. client-specific instruction for case fulfillment
  16. 24. a question or a request to the reviewer to clarify a portion of the review.
  17. 28. a specific condition or circumstance is not covered by the insurance policy.
  18. 29. an MRIoA website application where our clients can submit and review requests.
  19. 30. the explanation of the reviewer’s opinion.
  20. 32. an MRIoA website application where our panel of reviewers can see and review cases that are assigned to them, submit their reports, and respond to clarifications.
  21. 33. a physician or pharmacist on the health team who complete reviews.
  22. 40. client-specific instruction
  23. 41. or S/O is sending the reviewer a notification to accept (or decline) extensive edits that were made by the completion team.
  24. 42. a physician contracted by MRIoA to complete reviews.
  25. 43. refers to the principles or standards of which something is judged or decided.
  26. 44. or Conflict of Interest refers to a situation where a person's or organization's personal interests could potentially influence their professional judgment, decisions, or actions.
  27. 47. or Utilization Review Accreditation Commission, an independent, non-profit organization that promotes health care quality through accreditation, certification, and measurement programs.