Health Professionals Sections - Fludara® (fludarabine phosphate) for injection

Administration Fees: A physician's charges for injecting a drug.

Allowed Charges: Charges for services rendered or supplies furnished by a health care provider, which would qualify as covered expenses and for which the insurer will pay in whole or in part, subject to any deductible or coinsurance.

Average Wholesale Price (AWP): The composite wholesale prices charged on a specific commodity as assigned by the drug manufacturer and used by Medicare Part B and most third-party payers as a basis for reimbursement.

Blue Cross Plan: A not-for-profit corporation operating under the approval of the Blue Cross Blue Shield Association and administering a prepayment program for the purchase of hospital services in a limited geographical area.

Blue Shield Plan: A not-for-profit corporation sponsored and/or approved by a medical society to administer a voluntary prepayment medical-surgical program in a limited geographical area, and operating under the membership standards of the Blue Cross Blue Shield Association.

Capitation: A payment methodology (used primarily by HMOs) whereby payment for services is subject to a fixed or "capitated" amount. Reimbursement can be capitated on a procedural, monthly, or per patient per month basis.

Carrier: A private insurer under contract with HCFA to administer Medicare Part B benefits. A carrier's main function is to compute reasonable charges and to pay claims for physician and other supplier services.

Claims Administrator: Any entity that reviews and determines whether to pay claims to enrollees or physicians on behalf of the health benefit plan. Claims administrators may be insurance companies or their designated claims review organizations, self-insured employers, management firms, third-party administrators, or other private contractors.

Claim Form: The form submitted to the payer by the provider of service (i.e., facility or physician) or the patient to receive reimbursement for a drug or medical service.

Coding: A system of uniform language used to accurately describe medical, surgical and diagnostic services, and thereby provide an effective means for reliable nationwide communications among physicians, patients and third parties.

Coinsurance: A type of cost-sharing whereby the insured or covered person pays a percentage of charges and the insurer pays the rest.

Coordination of Benefits: The specific term used to designate the antiduplication provision designed by the group health insurance industry through the Health Insurance Association of America (HIAA) to limit benefits for multiple carriers of group health insurance to 100 percent of the expenses covered and to designate the order in which the multiple carriers are to pay benefits.

Copayment: A type of cost-sharing whereby the insured or covered persons pay a specified flat dollar amount per unit of service or unit of time, and the insurer pays the rest of the cost.

Cost-Sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayment, and coinsurance amounts.

Coverage: A term used to describe the possible payment status of a health service or device for which the insurer might provide reimbursement.

Covered Services: Specific services and supplies for which third-party payers may provide reimbursement.

CPT-4 Codes: A coding system for reporting medical services and procedures performed by physicians or their designates.

Deductible: The amount of coverage charges the insured party must assume or pay before the insurance company benefits became payable. A deductible is most common in major medical policies; however, it may also be incorporated in basic plan policies.

Denial: The refusal of a payer to cover a particular benefit, such as a drug or medical service.

Efficacy: The effectiveness of a drug in treating a specific condition or disease.

Fee-for Service: Traditional payment methodology whereby payment is made based on actual services provided. Reimbursement amount is based on the reasonable and customary charges for a particular geographic area.

Fiscal Intermediary: The administrator that has contracted with providers of service to process claims for reimbursement for Medicare Part A. Responsibilities include determining reasonable cost for covered items and services, making payments and guarding against unnecessary use of covered services. Intermediaries also arrange for home health and outpatient hospital services reimbursement under Medicare part B.

Freestanding Facility: From a payer's perspective, a non-hospital-connected facility which renders some type of outpatient treatment or care (i.e., diagnostic imaging center, cancer treatment center, dialysis treatment facility.

Health Care Financing Administration (HCFA): The division of the federal Department of Health and Human Services that oversees the administration of the Medicare and Medicaid programs.

HCFA Common Procedure Coding System (HCPCS): A list of codes used by providers to describe medical services they render. The HCPCS, recognized by government and private insurers, includes CPT-4 codes, alphanumeric codes representing supplies or procedures not listed in CPT-4, and local codes.

Health Maintenance Organization (HMO): An organization that provides a wide range of comprehensive health care services for a specified group at fixed periodic payment.

ICD-9-CM: A coding system for reporting diseases.

"J" Code: A five-position alphanumeric HCPCS code beginning with the letter "J" and used to describe drugs that are injected or infused.

Local Codes: An identifying code that is not listed in the CPT-4 or HCPCS and that is developed and utilized for a specific insurer.

Malpractice Expense (RVU): The relative value unit used to account for professional malpractive liability to perform a service.

Managed Care: Health care systems that integrate the financing and delivery of appropriate health care services to covered individuals by arrangements with selected providers to furnish a comprehensive set of health care services, explicit standards for selection of health care providers, formal programs for ongoing quality assurance and utilization review, and significant financial incentives for members to use providers and procedures associated with the plan.

Medicaid: A federal-state funded program that provides medical care financing for the poor and medically needy in the U.S. Medicaid covers basic health services, and in most states, outpatient prescription drug benefits.

Medical Necessity: Medical information justifying that the service rendered was reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.

Medicare: Popular name for benefits provided by Title XVIII of the Social Security Act, which includes two programs of health insurance protection for the aged and medically disabled: Part A covers hospitalization and related institutional care; Part B covers physician care, outpatient services, and other health services.

Medi-Gap: A Medicare or Medi-Gap supplement designed to fill the gaps in Medicare payments. These policies provide coverage of Part A hospitalization coinsurance, or pay toward Part B expenses, such as the annual $100 medical benefits deductible or the 20% of coverage that Medicare approves but does not pay for.

Modifier: A two-position (usually) numeric that is added to a CPT-4 code to indicate that the service or procedure performed was altered in some way (i.e., bilateral procedure, more than one physician was needed, or additional services were performed). Separate five-digit CPT-4 codes are also used to describe modified services.

Office Visit: A billable physician service that can be coded as problem-focused, detailed, or comprehensive for either a new or an established patient.

Participating Providers: Physicians who have signed agreements with an insurer to accept the insurer's payment for services as payment in full.

Payer: Any entity which is liable to pay for the medical costs of injury, disease or disability of a recipient.

Practice Expense RVU: The relative value unit for the practice expense (i.e., office rent, salaries of office workers, and supplies) for a particular service.

Preferred Provider Organization (PPO): An arrangement whereby a third-party payer contracts with a group of medical care providers who furnish services at lower-than-usual fees in return for prompt payment and a certain volume of patients.

Prescription Drug Plan: Usually a provision under medical coverage plans whereby the subscriber can obtain prescription drugs without incurring potentially large out-of-pocket expenses. Different types of prescription drug plans are available.

Prior Review/Authorization: Prior assessment by payer or payer's agent that proposed services, such as hospitalization, are appropriate for a particular patient. Payment for services also depends on whether the patient and the category of service are covered by a benefit plan.

Provider: A person (e.g., physician) or place (e.g., hospital) licensed to deliver health care services.

Reasonable and Customary Charge: A charge for health care that is consistent with the going rate or charge in a certain geographical area for an identical or similar service.

Reimbursement: The amount paid for a covered service.

Rejection: When a payer denies payment for a submitted claim. It is possible that the claim was incorrectly submitted, or was incomplete, and if that is the case, the claim may be re-submitted.

Resource-Based Relative Value System (RBRVS): A system developed by HCFA to determine benefits paid to physicians based on established Relative Value Units (RVUs) for similar procedures and services. The three components of each established value are: work RVU, practice expense RVU and malpractice expense RVU.

Third-Party Administrator (TPA): Organization that processes health plan claims without bearing any insurance risk.

Third-Party Payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.

Work RVU: The relative value unit for the physician work involved in rendering a service. This value would be determined based on the time, intensity level, and technical skills required to provide the service.

Please see full Prescribing Information for FLUDARA®.