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Mod 5 Ch 15
Ch 15 Medical Insurance
| Term | Definition |
|---|---|
| EDI | Electronic Data Interchange Involving the computerized transfer of health care information between 2 parties for specific purposes. |
| NPI | National Provider Number # assigned to Providers by CMS for submitting insurance claims. |
| Supporting Claim Documentation | Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim. |
| Past Filing Limits | Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected. |
| Medicare | Federal Health Insurance program for people over age 65. |
| Medicare Part A | Hospital Insurance that is automatic if you receive Soc Sec benefits. |
| Medicare Part B | Fee-for-service, optional program that requires insured to pay income-based premiums. |
| Medicare Part C | Medicare Advantage Managed Care |
| Medicare Part D | Prescription Drug Coverage (limited) |
| WC | Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness. |
| Tri-Care | (formerly CHAMPUS) Government insurance program for active duty and retired military personnel. |
| CMS | Centers for Medicare and Medicaid Services |
| ABN | Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare. |
| Out-of-Pocket Expenses | Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers. |
| Primary Payer | 1st payer, usually responsible for more money or higher charge |
| Secondary Payer | MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose). |
| Physician Fee Schedule | The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient. |
| VOB | Verification of (Insurance) Benefits Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt. |
| Pre-Authorization | Contacting the insurance company to obtain permission for a procedure. |
| COB | Coordination of Benefits Determining the Primary / Secondary insurances |
| Co-Pay | Fixed $ amount that the patient pays |
| Co-Insurance | Fixed % that the patient pays |
| Deductible | Monetary amount patient must pay before insurance kicks in. |
| CMS-1500 | Uniform billing format used for medical claims. |
| Medicaid | MCD - Health benefit program for low-income patients. ALWAYS billed 2nd. |
| PCP | Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations. |
| CHAMPVA | Insurance through government for disabled veterans. |
Created by:
vanstellee
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