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Insurance programs have a lot of special words. Here’s what they mean.
Billing abuse applies to a range of improper billing behaviors or practices of providers, including, but not limited to:
- Billing for a non-covered service
- Billing for a service that was not provided or billing twice for the same service
- Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered)
- Upcoding, or billing for a more expensive service than the one that was delivered
- Inappropriately allocating costs on a cost report.
Personal abuse happens when another person does something on purpose that causes you mental or physical harm or pain. This may include physical abuse, sexual abuse, or emotional abuse.
Your ability to get needed medical care and services on a timely basis.
A denial or a limited authorization by the managed care plan of a requested item or service, or a reduction or termination of a previously authorized service. Actions can be appealed by the participant, the participant’s authorized representative, or a provider acting on the participant’s behalf.
Activities of Daily Living (ADLs)
ADLs are activities you usually do during a normal day such as getting in and out of bed, dressing, bathing, eating, and using the bathroom.
An administrative hearing is a second level of appeal if the first level of appeal with PHP is not decided wholly in the participant’s favor. For PHP Care Complete participants, the administrative hearing is conducted by the FIDA Administrative Hearing Unit within the New York State Office of Temporary and Disability Assistance.
The doctor responsible for admitting a patient to a hospital or other inpatient health facility.
Advance directives are written instructions—such as a living will or durable powers of attorney for health care recognized under state law and signed by a patient—that explain the patient’s wishes concerning the provision of health care if the patient becomes incapacitated and is unable to make those wishes known.
A person who gives you support or protects your rights.
Ambulatory surgical center
A place other than a hospital that does outpatient surgery. At an ambulatory surgery center, you might stay for only a few hours or for one night.
An appeal is a special kind of complaint you make if you disagree with a decision (i.e., plan action) to deny or reduce a request for services or to pay for services you already received. An appeal is your request for a review of an action taken by PHP related to your covered items or services. You can file an appeal with PHP by calling Participant Services or your Care Management Team or by writing a letter.
The gathering of information to evaluate your health and other needs. Assessments are performed when you first enroll and at least every 180 days thereafter. You may also receive an assessment if you have a sudden change in your condition or if your caregiver becomes unable to assist you.
Authorization from Interdisciplinary Team (IDT)
Each participant in PHP will have an Interdisciplinary Team to assist in managing his or her needs and services and the development of a written person-centered care and service plan, or “Life Plan.” Most covered services that a PHP participant needs will be authorized by the Interdisciplinary Team and included in the Life Plan.
An organization or adult person authorized under law, to act on behalf of a Participant. Unless otherwise stated, the Representative will have all the rights and responsibilities of a Participant or party in filing a grievance, and in obtaining an organization determination or in dealing with any of the levels of the appeals process.