Glossary

Acronyms
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ASSOCIATION FOR ELECTRONIC HEALTH CARE TRANSACTIONS

An organization that promotes the use of EDI in the health care industry.

ASSUMPTIONS

Values relating to future trends in certain key factors that affect the balance in the trust funds. Demographic assumptions include fertility, mortality, net immigration, marriage, divorce, retirement patterns, disability incidence and termination rates, and changes in the labor force. Economic assumptions include unemployment, average earnings, inflation, interest rates, and productivity. Three sets of economic assumptions are presented in the Trustees Report:

  1. The low cost alternative, with relatively rapid economic growth, low inflation, and favorable (from the standpoint of program financing) demographic conditions;
  2. The intermediate assumptions, which represent the Trustees' best estimates of likely future economic and demographic conditions; and
  3. The high cost alternative, with slow economic growth, more rapid inflation and financially disadvantageous demographic conditions.

See also Hospital assumptions.

ATTACHMENT(S)

Information, hard copy or electronic, related to a particular claim. Attachments may be structured (such as Certificates of Medical Necessity) or non-structured (such as an Operative Report). Though attachments may be submitted separately, it is common to say the attachment was "submitted with the claim."

ATTENDING PHYSICIAN

Number of the licensed physician who would normally be expected to certify and recertify the medical necessity of the number of services rendered and/or who has primary responsibility for the patient's medical care and treatment.

AUTHORITATIVE APPROVAL

Method or type of approval that requires a determination that the service is likely to have a diagnostic or therapeutic benefit for patients for whom it is intended.

AUTHORITATIVE EVIDENCE

Written medical or scientific conclusions demonstrating the medical effectiveness of a service produced by the following:

  • Controlled clinical trials, published in peer-reviewed medical or scientific journals;
  • Controlled clinical trials completed and accepted for publication in peer-reviewed medical or scientific journals;
  • Assessments initiated by CMS;
  • Evaluations or studies initiated by Medicare contractors;
  • Case studies published in peer-reviewed medical or scientific journals that present treatment protocols.
AUTHORIZATION

MCO approval necessary prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.)

AUTOMATED CLAIM REVIEW

Claim review and determination made using system logic (edits). Automated claim reviews never require the intervention of a human to make a claim determination.

AVERAGE MARKET YIELD

A computation that is made on all marketable interest-bearing obligations of the United States. It is computed on the basis of market quotations as of the end of the calendar month immediately preceding the date of such issue.

BABY BOOM

The period from the end of World War II through the mid-1960s marked by unusually high birth rates.