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Kinn's Chapter 20

Allowed charge maximum amount of money many third party payers will allow for a service.
Authorization An alphanumeric number issued by the insurance company giving approval of a procedure or service.
Beneficiary An individual entitled to receive benefits from an insurance policy or program or from a government entitlement program.
benefits The amount payable by an insurance company for a monetary loss to an individual by that company.
Birthday Rule when an individual is covered under two insurance policies, the insurance plan of the policy holder whose birthday comes first in the calendar year becomes primary insurance (month and day).
Coordination of Benefits(COB) Find the primary insurance and secondary when person have more than one policy.
Capitation Payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for pts. enrolled during a specific period of time.
Carriers Companies that assume the risk of an insurance policy.
CHAMPUS Civilian Health and Medical Program of the Uniformed Services.
CHAMPVA Civilian Health and Medical Program of the Dept. of Veterans Affairs.
Co-insurance where insurance company and policy holder share the cost of covered losses in a specified ratio.
Commercial insurance plans Reimburses the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the insurance policy.
Co-Payment The sum of money paid at the time of service; a form of coinsurance.
Deductible Specific amount of money the patient must pay out of pocket yearly before the insurance carrier begins paying.
Dependents Spouse, children and sometimes domestic partner or other individuals designated by the insured who are covered under a health plan.
Disability Income Insurance Provides periodic payments to replace income when an insured person is unable to work due to illness, injury, or disease.
Effective Date The date on which an insurance policy takes effect so that benefits are payable.
Eligibility Term that indicates whether a patients insurance coverage is in effect and is eligible for payment of insurance benefits.
Exclusions Term limitations on an insurance contract for which benefits are not payable.
Explanation of Benefits (EOB) A letter or statement from the insurance carrier that describes what was paid denied, or reduced in payment, also info about the patients deductible amounts, coinsurance and allowed amounts.
Explanation of Medicare Benefits (EOMB) A letter or statement from Medicare that describes what was paid, denied, or reduced in payment. also allowed amounts, deductibles, and coinsurance.
Fee for Service An established schedule of fees set for services performed by providers and paid for by the patient.
Fiscal Intermediary An organization that contracts with the government to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical supplies or services.
Government Plans Medicare, Medicaid, Tricare, CHAMPVA, and Worker's Comp
Group policy Insurance written under a policy that covers a number of people through an employer.
Guarantor Person responsible for paying a medical bill.
Health Insurance A protection in return for periodic premium payments that provides reimbursement of expenses resulting from injury or illness.
HIPPA Designed to improve portability continuity of health insurance coverage, to combat waste, fraud, and abuse in the health insurance and delivery.
Indemnity Plans pay for all or a share of the cost of covered services, regardless of which physician, hospital or healthcare professional is used.
Individual Policy designed specifically for the use of one person and his/her dependents.
Insured Individual/organization covered by a insurance policy according to policy terms.
Managed Care Plans An umbrella term for all healthcare plans that provide healthcare services in return for preset monthly payments and coordinated care through a defined network of PCP's and hospitals.
Medical Savings Account (MSA) Tax deferred bank or savings account that are combined with a low premium, high deductible insurance policy and designed for individuals or families who choose to fund their own healthcare.
Medicaid Federally and Stated-sponsored health insurance program for the medically indigent.
Medicare A federally sponsored health insurance program for those 65 yrs and older or individuals under 65 and disabled.
Medigap A term applied to private insurance products that supplement Medicare insurance.
PAR Physician or other healthcare provider who enters into a contract with a specific insurance company or program and agrees o abides by their rules and regulations.
Policy Holder The person who pays a premium to an insurance company and whose name the policy is written in exchange for protection.
Premium Periodic monthly, quarterly, or annual payment of a specific sum of money to an insurance company for which the insurer, in return, agrees to provide certain benefits.
PCP Also referred to as the gatekeeper, responsible for the care of a patient for some HMO's.
Referral Term used when a primary care physician wants to send a patient to a specialist.
Remittance Advice (RA) An explanation of benefits that comes from Medicaid.
Resourced Based Relative Value Scale(RBRVS) Fee schedule designed to provide national uniform payment of Medicare benefits after adjustment to reflect differences in practice cost across geographical areas.
Rider Special provision or group of provisions that may be added to a policy to expand or limit the benefits payable.
Service Benefit Plans Provide benefits in the form of certain surgical and medical services rendered.
Third Party Administrator (TPA) An organization that processes claims and performs other business related functions for a health plan.
Third Party Payers (TPP) Entities that make payment on an obligated or debt but are not parties of the contract that created the debt.
Hospitalization Pays the cost of all or part of the insured person's hospital room and board and specific services per DRG guidelines.
Surgical Pays all or part of a surgeon's or assistant surgeon fees
Basic Medical Outpatient/physician office services, radiologic, labs, and diagnostic fee.
Major Medical Prolonged and Catastrophic illness or injury, takes over where basic medical , hospitalization and surgical benefits end.
Disability Accident or illness resulting in an inability for the patient to work, cash benefits paid in lieu of salary while patient is out of work.
Dental Preventive care and/ or treatment, and repair of teeth and gums, typically 100% preventive and 50% repair and treatment.
Vision Eye exam and glasses
Medicare supplement Deductible and co-insurance amounts unpaid by Medicare- Medigap.
Life insurance Loss of life, lump sum payment
Long Term Care Skilled Nursing or rehab
Special Risk Protects in the event of a certain type of accident.
Three advantages of managed care concept Healthcare cost are contained, Establish fee schedule are used, most preventive services are covered.
Usual, Customary, and Reasonable UCR- insurance companies agree to pay on the basis of all or a percentage of a UCR fee.
Level 1 codes CPT codes
Level 2 codes HCPCS- 7 alphanumeric digit codes medical services and supplies
series 99 E & M
series 7 radiology
series 8 laboratory
Created by: mrsdancona