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Health Ins Basics

Health Insurance Study Guide

Insurance Basics Study GuideAnswers
Universal Claim Form (Why?) To facilitate the standardization of the claims process. Mid 1970's the HealthCare Financing Adminstration created HCFA-1500. In 1990 the CMS-1500 form was created by Center for Medicare & Medicaid Services).
Universal Claim Form (Boxes?) There are a total of 33 boxes. The top portion is for the patient/insured information (Blocks 1-13), The bottom portion is for the physician/supplier information (Blocks 14-33)
Universal Claim Form (Demographics?) Patient information name, address, SS# and employment.
Universal Claim Form (ASCII) American Standard Code for Information Interchange. ASCII is the most common format used for text files in computers and on the internet.
Encounter Form Document used by most medical practices. This multipurpose billing form is known by many names (e.g. superbill, routing form, patient service slip).
Ledger Form Is an accounting form on which professional service descriptions, charges, payments, adjustments and current balance are posted chronologically.
Manual Claims Follow-up A process used to track claims and deliguent claims resolved before it is too late to resubmit. An example of a claims follow-up system is an insurance log or insurance register.
Managed Care Managed care is a complex healthcare system in which physicians, hospitals, and other healthcare professionals organize an interrelated system of people and facilities that communicate with one another and work together as a unit, called a Network.
TPA Third-party administration (TPAs) to manage and pay their claims. A TPA is a person or organization who process claims and performs other contractual administrative services.
Employee Retirement Income Security Act of 1974 Self-insured plans sometimes called ERISA Plans. The only law that governs self-insured plans is the federal law known as ERISA. ERISA sets minimum standards for pension plans in private industry, which is how most self-insured employers fund programs.
POS A model is a "hybrid" type of managed care (also referred to as open ended HMO) that allows patients to use the HMO provider or go outside the plan and use any provider they choose.
Grievance-A written complaint submitted by an individual covered by the plan concerning the following: 1. insurer's decisions, policies, or actions related to availability, delivery, or quality of healthcare services. 2. Claims payment or handling or reimbursement for services. 3. The contractual relationship between a covered individual an an insurer. 4. Outcome of an appeal.
Medicaid (Medi/Medi) Dual coverage, dual eligibility. Individuals may receive Medicare services for which they are entitled and other services available under that state's Medicaid program.
Family Individual and family health insurance plans are usually described as either "indemnity" or "managed-care" plans. Put broadly, the major differences concern choice of healthcare providers, out-of-pocket costs and how bills are paid.
Clearinghouse Is a company that receives claims from healthcare providers and specializes in consolidating the claims so they can send one transmission to each third-party payer containing batches of claims.
Indemnity Plan AKA as Fee-for-Service (FFS) is a traditional kind of healthcare policy where patients can choose any healthcare provider or hospital they want (including specialists) and change physicians at any time.
Third Party Payer Is any organization (e.g. Blue Cross and Blue Shield, Medicare, Medicaid, or commercial insurance company) that provides payment for specified coverages provided under the health plan.
Group Policy Group insurance is a contract between an insurance company and an employer (or other entity) that covers eligible employees or members.
Managed Care Plan A managed care plan typically involves the financing, managing, and delivery of healthcare services and is composed of group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, but quality, service.
Insurance Cap Most FFS plans have an insurance cap, which limits the amount of money the policyholder has to pay out-of-pocket for any one incident in any one year.
Reasonable and Customary The term "reasonable and customary" is used to refer to the commonly charged or prevailing fees for health services within a geographic area.
Participating Provider One who participates through a contractual arrangement with a healthcare service contractor in the type of health insurance in question, he or she agrees to accept the amount paid by the carrier as payment in full.
Self-insurance Program Means that when an employee needs healthcare, the employer, not an insurance company is responsible for the cost of medical services.
Capitation A reimbursement system in which healthcare providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses. The word "capitation" comes from the Latin phrase "per capita", meaning "each head".
Preauthorization Preauthorization is a procedure required by most managed healthcare and indemnity plans before a provider carrie out specific procedures or treatments for a patient typically inpatient hospitalization and certain diagnostic tests.
Categorically Needy Individuals in the categorically needy group receive medical assistance because their income falls within the poverty or Family Medical income guidelines or a result of SSI eligibility.
Medicare Part A Medicare Part A (hospital insurance) helps pay for services for the following types of healthcare: inpatient hospital care, inpatient care in skilled nursing facility, home healthcare, hospice care, blood.
Medicare Part B-is medical insurance financed by a combination of federal government funds and beneficiary premiums, which helps pay for the following: medically necessary physicians' services, outpatient hospital services, clinical laboratory services, durable medical equipment, blood (received as an outpatient.
Medicare Part D Coverage for prescription drugs.
Donut Hole Period during which a Medicare beneficiary is responsible for all prescription drug expenses until a total of $3600 is spent out-of-pocket. Period of noncoverage.
Network An organized, interrelated system of people and facilities that communicate with one another and work together as a unit, called a Network.
Patient Sequence Step 1 Patient Cal for Appointment
Patient Sequence Step 2 Patient Enters the Office
Patient Sequence Step 3 Patient Examination
Patient Sequence Step 4 Patient Check Out
Patient Sequence Step 5 CMS-1500 Generated
Patient Sequence Step 6 Follow-up
Created by: MichaelAJ007