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Kinn's Chapter 20
| Term | Definition |
|---|---|
| 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
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