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Capitation: A payment method in which the health care provider is paid a set dollar amount determined by a per-member, per-month (pmpm) calculation to deliver medical services to a specified group of people.

Catastrophic disability: The loss of speech, loss of hearing in both ears, sight in both eyes, or use of two limbs.

Categorically needy: A classification of individuals and/or families who meet certain eligibility requirements allowing them to qualify for Medicaid or other Federal/State programs due to the "category" they fall into, e.g., low income families with children; aged, blind and disabled individuals; and the elderly who meet certain financial criteria. http://cms.hhs.gov/medicaid/eligibility/criteria.asp

CHAMPVA: Acronym for the Civilian Health and Medical Program of the Department of Veterans Affairs, which is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries.

Chief complaint (CC): A brief statement describing the illness, injury, signs, or symptoms, usually stated in the patient's words, that prompted the encounter with the health care provider.

Clean claim: An insurance form that has been completely and accurately filled out in such a manner that the physician (or other health care provider) receives the maximum reimbursement allowed by the third-party payer that can be supported by the medical record. The claim form follows required guidelines; has no typographical or punctuation errors; all blocks contain the required data; and correct diagnostic (ICD-9) code(s) and procedure and service codes (CPT) are correctly documented. Bottom line: The claims processing office can pay the claim without delay or without having further contact with the submitting medical facility.

Clearinghouse: A company that performs centralized claims processing for health care providers and third-party payers. Claims are sent electronically to clearinghouses that then check them for accuracy and send them on to various insurance carriers.

Clinical: The medical picture established of the patient's precise illness or injury based on actual observation and treatment.

Clinical Laboratory Improvement Amendments (CLIA): A program to ensure quality laboratory testing. The Centers for Medicare/Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through this program. Although all clinical laboratories must be properly certified to receive Medicare or Medicaid payments, CLIA has no direct Medicare or Medicaid program responsibilities.

CMS-1500 (formerly HCFA-1500): The name given to the universal claim form used to report outpatient services by all government health programs and most commercial, or private, payers. It was created by the Health Care Financing Administration (HCFA, pronounced "hic-fa") and approved by the American Medical Association (AMA) Council on Medical Services. The form was originally developed for submitting Medicare claims and was later adopted by most other third-party payers to standardize the claims process. It is printed in red ink to optimize the scanning process that "reads" the entries electronically.

CMS-1500 Claim Form: (see CMS-1500)

Coinsurance: A common policy provision in medical insurance where the insured person and the insurer share the covered losses under a policy in a specified ratio, i.e., 80 percent by the insurer and 20 percent by the insured.

Compliance: The act of meeting the requirements or cooperating with a specific rule or law. Under HIPAA, compliance means to set up and govern office procedures and protocols according to the specific guidelines outlined in its regulations.

Compliance date: Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective date of the associated final rule for most entities, but 36 months after the effective date for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective date, but can be longer for small health plans and for complex changes.

Consolidated Omnibus Budget Reconciliation Act (COBRA): COBRA is a law that makes an employer let you remain covered under the employer's group health plan for a period of time after: the death of your spouse, losing your job, having your work hours reduced, or getting a divorce. You may have to pay both your share and the employer's share of the premium.

Coordination of benefits (COB): If the patient is covered under more than one insurance policy, the "coordination of benefits" principle states that he or she cannot collect payment amounts that total more than what was charged by the health care provider.

Copayment: A specified dollar amount that a patient must pay the health care provider for every office visit or medical encounter. It is usually a flat fee, such as $10 or $20 that the patient pays out of pocket, beyond any applicable deductible, for each encounter. (Copayments usually range between $5 and $25.)

Corporation: An entity formed and authorized by law to act as a single person although made up of one or more persons and legally given the power of various rights and duties including the capacity of succession. Often medical practices are incorporated to limit certain types of liability.

Cost containment: Methods by which an insurance carrier reduces the benefit payment or costs associated with a health plan. Examples of cost containment include UCR fees, preferred provider discounts, and preauthorization requirements for certain services.

Covered benefit: Any hospital, medical, and miscellaneous health care expenses incurred by the insured that are payable either partially or fully under his/her health insurance policy. Also called "covered expenses," "covered benefits," or "covered charges."

Covered charges: Any hospital, medical, and miscellaneous health care expenses incurred by the insured that are payable either partially or fully under his/her health insurance policy. Also called "covered expenses," "covered benefits," or "covered charges."

Covered services: Any hospital, medical, and miscellaneous health care expenses incurred by the insured that are payable either partially or fully under his/her health insurance policy. Also called "covered expenses," "covered benefits," or "covered charges."

Credit balance: When an individual's accounts receivable ledger show that total payments have exceeded total charges.

Crossover claim: When one carrier (Medicare, for example) automatically transmits claim information to a secondary carrier (e.g., Medicaid).

Current Procedural Terminology (CPT) coding system: A systematic listing of services and procedures performed by physicians and other health care providers using a 5-digit format (with occasional 2-digit modifiers). CPT codes provide a uniform language with third-party payers for reimbursement purposes. The American Medical Association (AMA) publishes an updated CPT coding manual on a yearly basis.