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Module C - Unit 3

Assignment of Benefits patient's written authorization giving the insurance company the right to pay the physician directly for billed charges.
Bankruptcy a condition in which a patient is protected by the court and all collection attempts muct cease.
Copayment amount specified by an insurance plan that the patient must pay before the plan pays (commonly used in managed care plans)
CPT Current Procedure Terminology
Crossover Claim patient is eligible for both Medicare and Medicaid (also called Medi/Medi)
Cycle Billing type of billing divided into groups
Deductible amount of eligible charges each patient must pay each calendar year before the plan begins to pay benefits.
Delinquent account past due
Fee Schedule schedule of the amount paid by a specific insurance company for each procedure or service. Amounts are determined by a claims administrator and applied to claims subject to the fee schedule of a provider's managed care contract.
Hospice patient-centered interdisciplinary program of care and supportive services for terminally ill patients and their families.
HCFA Healthcare Financing Administration
HMO (Health Maintenance Organization) type of managed care plan in which a range of health care services are made available to plan members for a predetermined fee (the capitation rate) per member, by a limited group of providers (such as physicians and hospitals).
Inpatient patient who remains within the medical facility at least overnight for care and/or treatment.
Insured individual who is covered under an insurance plan.
Outpatient patient undergoing medical treatment which does not necessitate staying overnight in the facility. Also referred to as ambulatory or a "23 hour hold."
Medicare health insurance for the elderly provided by the United States government.
Medicaid designed for the medically indigent, or persons without funds, comes from state funds, with some money to offset costs.
Preauthorization a requirement of Medicare and insurance companies to obtain prior approval for surgery and other procedures in order to receive reimbursement.
PCP Primary Care Physician or Primary Care Provider
PPO Preferred Provider Organization
Premium amount paid for insurance coverage.
Statute refers to time a legal collections suit may be brought against debtor
Subscriber person who holds a health benefit plan/contract. This plan, contract, or policy may include other family members.
UCR Usual, Customary, Reasonable Method
Acquired Immune Deficiency Syndromes (AIDS) series of infections that occur as a result of infection by the human immunodeficiency virus (HIV) wich causes the immune system to break down.
Ambulatory Care referes to health service facility which provides health care to individuals who are not hospitalized.
Diagnostic Related Groups (DRGs) designations used to identify reimbursement per condition in a hospital. Used for Medicare patients.
Legionnaires' Disease severe, sometimes fatal disease, caused by a baccilus that is inhaled. First occurence was at the Legionnaire's convention in 1976.
Medical Privileges ability of a physician to admit patients and practice medicine at a particular hospital.
Primary Care basic or general health care a person receives for common illnesses. A primary care physician is the one to whom the patient and/or family will go to seek most medical care.
Proprietary Hospital a hospital that operates on a for-profit basis.
Benefit Period period of time for which payments for Medicare inpatient hospital benefits are available.
Claim written and documented request for reimbursement of an eligible expense under an insurance plan.
Coding Transferring narrative description of diseases and procedures into a number
Coinsurance a cost-sharing provision requires the insured to assume a portion of the cost of covered services.
Indemnity Schedule list of determined amounts to be paid for specific services by the insurance carrier on behalf of the insured.
Medically Indigent person without insurance coverage and with no funds.
Nonparticipating Provider provider who decides not to accept an allowable charge as the full fee for care.
Participating Provider one who accepts assignment and is paid directly by the plan.
Prepaid Plan a group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or capitated basis (also called managed care plan).
Rider a written exception to an insurance contract, expanding, decreasing, or modifying coverage of an insurance policy.
Created by: sgaston712