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Actual charge Amount provider actually bills a patient, which may differ from the allowable charge.
Adjudication The determination of the reimbursement payment based on the member's insurance benefits.
Adverse selection Enrollment of excessive proportion of persons with poor health status in a healthcare plan of healthcare organization.
Allowable charge Average or maximum amount the third-party payer will reimburse providers for the service.
Appeal Request for reconsideration of denial of coverage or rejection of claim.
Assignment of benefits. contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services, to bill the beneficiary only for any coinsurance or deductible that may be applicable, and to accept the Medicare payment as pymnt full
Benefit Healthcare service for which the healthcare insurance company will pay.
Benefit cap Total dollar amount that a healthcare insurance company will pay for covered healthcare services during a specified period, such as a year or lifetime.
Benefit period Length of time that a health insurance policy will pay benefits for the member, family, and dependents (if applicable) (also known as policy limit).
Catastrophic expense limit Specific amount, in a certain timeframe, such as one year, b eyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan.
Center of excellence Healthcare organization that performs high volumes of service with correspongingly high quality; often recognized by medical peers for its expertise, cost-effectiveness, and superior outcomes. Negotiated discount rates.
Certificate holder Member of a group for which the employer or association has purchased group healthcare insurance. Insured, Member, Policyholder, Subscrib er.
Certificate number Unique number that identifies the holder (enrollee, member, or subscriber) of a healthcare insurance policy (also known as identification number, member number, policy number, and subscriber number).
Certificate of insurance Formal contract, between healthcare insurance company and individuals or groups purchasing the healthcare insurance, that details the provisions of the healthcare insurance policy (certificate of coverage, evidence of coverage, or summary plan description
Claim submission Process of transmitting claims requesting payment to payers.
Claim attachment Documentation of supplemental information that assists in the understanding of specific services received by an individual and in the determination of payment (such as documentation that supports medical necessity).
Clean claim Request for payment that contains only accurate information (no errors in data).
Clearinghouse Entity that acts as intermediary between providers and payers and converts health data in nonstandardized formats, such as paper, into standardized electronic formats for processing. May also run software-based audits verify compliance w/payer's edits
Coinsurance Cost sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met. The percentage may vary by type or site of service.
Consumer-directed (consumer-driven) healthcare plan (CDHP) Form of healthcare insurance characterized by influencing patients and clients to select cost-efficient healthcare through the provision of information about health benefit packages and through financial incentives.
Contracted discount rate Type of fee-for-service reimbursement in which the third-party payer has negotiated a reduced (discounted) fee for its covered insured. Discounted fee-for-service
Coordination fo benefits (COB) Method of integrating benefits payments form all health insurance sources to ensure that payments do not exceed 100 percent of the covered healthcare expenses
Copayment Cost-sharing measure in which the policy or certificate holder pays a fixed dollar amount (flat fee) per service, supply, or procedure that is owed to the healthcare facility by the patient.
Cost sharing Provision of a healthcare insurance policy that requires policyholders to pay for a portion of their healthcare services; a cost-control mechanism.
Covered condition Health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay.
Covered service (expense) Specific service for which a healthcare insurance company will pay. Benefits
Creditable coverage Prior healthcare coverage that is taken into account to determine the allowable length of pre-existing condition exclusion periods (for individuals entering group health plan coverage).
Credited coverage Reduction of waiting period for pre-existing condition based on previous creditable coverage. Credited coverage may be calculated on a day-by-day basis or other method that is at least as favorable to the indivdual. To receive credit for previous 63 day
Deductible Annual amount of money that the policy-holder must incur (and pay) before the health insurance will assume liability for the remaining charges or covered expenses.
Defensive medicine Medical tests, visits, and procedures to avert or prevent medical litigation, to reduce medical liability, and to avoid claims of malpractice. Defensive medicine is associated with increased costs of healthcare that do not benefit patients or clients.
Dependent An insured's spouse and unmarried children, claimed on income tax. The maximum age of dependent children varies by policy. A common ceiling is 19 years of age, with continuation to age 23 provided child is a full-time student accredited school
Dirty (dingy, unclean) claim Claim that has a defect or improperiety.
Edit Algorithm in computer software applications that is an internal check for consistency and accuracy.
Electronic claim submission Paperless transmission of claims with health data in standardized format through computer software system or via the Internet.
Electronic funs transfer (EFT) Electronic exchange or transfer of meney from one account to another through computer software systems.
Electronic remittance advice (ERA) Electronic document that details the payer's determination fo the payment, denial, or suspension of a provider's claim.
Eligibility Set of stipulations that qualify a person to apply for healthcare insurance, examples include percentage of the appointment or duration of employment.
Enrollment Initial process in which new individuals apply and are accepted as members (subscribers, enrollees) of healthcare insurance plans.
Evidence of insurability Statement or proof of a health status necessary to obtain healthcare insurance, especially private healthcare insurance.
Exclusion Situation, instance, condition, injury, or treatment that the healthcare plan states will not be covered and for which the healthcare plan will pay no benefits (synonym is impairment rider).
Explanation of benefits (EOB) Report sent from a healthcare insurer to the policyholder and to the provider that describes the healthcare service, its cost, applicable cost sharing, and the amount the healthcare insurer will cover. The remainder is the policyholder's responsibility.
Flexible spending (savings) account (FSA) Special account funded, by employees' contributions, to pay for qulified medical care and expenses. Employees determine the pretax deduction that is deposited into the account, up to the limit set by the employer. Funds from one FSA plan year No ROLL
Formulary List of preferred drugs, including brand-name and generic.
Group number Number identifiying the employer, association, or other entity that purchases healthcare insurance for the individual members of the group. Individuals in the group have the same set of healthcare benefits.
Health reimbursement arrangement (HRA) Combination fo an employee-benefit health insurance plan and a separate arrangement to reimburse employees for all or a portion of the qualified medical expenses not paid by the health insurance policy. Although often referred to as health reimbursemen
Health savings account (HSA) Special pretax saving account into which employees, and sometimes employers, deposit money that subscribers can later withdraw to pay for qualified medical care and expenses. Unused funds can roll forward to subsequent years.
High deductibel health plan (HDHP) Most common type of sonsumer-directed healthcare; insurance policy's deductibels are higher than traditional healthcare insurance plans. Combined with health savings accounts or health reimbursement arrangements. HDHPs allow subscribers to pay for quali
High-risk pool An insurance plan (often a state healthcare insurance plan) that covers unhealthy or medically uninsurabel people whose healthcare costs will be higher than average and whose utilization of healthcare services will be higher than average. unhealthy indiv
Indemnity health insurance Traditional, fee-for-service healthcare paln in which the policyholder pays a monthly premium and a percentage of the usual, customary, and reasonable healthcare costs, and the patient can select the provider.
In-network Set of physicians, hospitals, and other providers who have formal agreements with health insurers under which patients and clients receive services at a discounted rate; preferred set of providers.
Insured Individual or entity that purchases healthcare insurance coverage. Certificate holder, Member, Policyholder, Subscriber.
Late enrollee Individual who does not enroll in a group healthcare plan at the first opportunity but enrolls later if the plan has a general open enrollment period.
Limitation Qualification or other specification that reduces or restricts the extent of the healthcare benefit.
Maximum out-of-pocket cost Specific amount, in a certain timeframe, such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan. Catastrophic expense limit, Stop-loss benefit.
Medical necessity Healthcare services and supplies that are proved or acknowledged to be effective in the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms and to be consistent with the community's accepted standard care
Medically uninsurabel An individual who has a preexisting health condition, a chronic disease, or both, who cannot obtain healthcare insurance through the usual mechanisms because of his or her high risk and high cost.
Medigap Type of private insurance policy available for Medicare beneficiaries to supplement Medicare Part A and / or Part B coverage.
Member Individual or entity that purchases healthcare insurance coverage. Certificate holder, Insured, Policyholder, Subscriber.
Moral hazard Any change in behavior that occurs as a result of becoming insured.
Open enrollment (election) period Period during which individuals may elect to enroll in, modify coverage, or transfer between healthcare insurance plans, usually without evidence of insurability or waiting period (Medicare uses the term election).
Out-of-network Set of physicians, hospitals, and other providers who lack formal discounted-rate agreemtents with health insurers. Patients and clients receive no descount and pay increased cost-sharing.
Out-of-pocket Payment made by the policyholder or member.
Point-of-service (POS) healthcare insurance plan Plan in which the determination fo the type of care, provider, or healthcare service is made at the time (point) that the service is needed.
Policy Binding contract issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury (also known as health plan agreement and evidence of coverage).
Policyholder Individual or entity that purchases healthcare insurance coverage. Insured, Certificate holder, member, subscriber.
Pre-existing condition Disease, illness, ailment, or other condition (whether physical or mental) for which, within six months before the insured's enrollment date of coverage, medical advice, diagnosis, care, or treatment was recommended or received.
Preferred provider organization (PPO) Entity that contracts with employers and insurers to render, through a network or providers, healthcare services to a group of members.
Primary insurer (payer) Entity responsible for the greatest proportion or majority of the healthcare expenses.
Prior approval (authorization) Process of obtaining approval from a healthcare insurance company before receiving healthcare services (also known as pre-certification).
Prudent layperson standard Standard for determining the need for emergency care based on what a prudent layperson (ordianry person) would believe or decide. A prudent layperson, possessing average knowledge about health and medicine, would expect that a condition could jeapardize
Remittance advie (RA) Report sent by third-party payer that outlines claim rejections, denials, and payments to the facility; sent via electronic data interchange.
Rider Document added to a healthcare insurance policy that provides details about coverage or lack of coverage for special situations that are not usually included in standard policies. May function as an exclusion or limitation.
Risk pool Group of people who will be covered by a healthcare insurance plan.
Secondary insurer (payer) Secondary insurer (payer) Entity responsible for the remainder of the healthcare expenses after the primary insurer pays.
Special enrollment (election) period Period during which individuals may elect to enroll in, modify coverage, or transfer between healthcare insurance plans, unually without evidence of insurability or waiting periods, because of specific work or life events, without regard to the healthcar
State healthcare insurance plan Nonprofit assoc or govemt agency created by state to provide healthcare insurance for people without coverage, usually because of pre-existing health conditions or chronic diseases; called health insurance association, comprehensive health high risk pool
Stop-loss-benefit Specific amount, in a certain timeframe, such as one year, beyond which all covered healthcare services for that policyholder or dependent are paid at 100 percent by the healthcare insurance plan.
Subscriber Individual or entity that purchases healthcare insurance coverage.
Supplemental insurance Additional healthcare insurance that fills in gaps (supplements) in comprehensive insurance or Medicare benefits; may be a cash benefit, per diem, or other form.
Tier Level of healthcare benefit.
Underwriting Process of identifying and classifying individuals' or groups' risk.
Waiting period Time between the effective date of a healthcare insurance policy and the date the healthcare insurance plan will assume liability for expenses related to certain health services, such as those related to pre-existing conditions.
Wellness program Program to promote health and fitness offered by employers and health insurance plans.
Wraparound Supplemental type of insurance policy that covers the gaps in other types of health insurance.
Write-off Amount deducted from a provider's claim; difference between the actual charge and the allowable charge. Some agreements between providers and healthcare insurance companies prohibit providers from charging patients this excess difference.
Created by: Lyn Slough