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Health Insurance & Claims Chapter 2

Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required. Ambulatory Payment Classification (APC)
Form used to submit outpatient insurance claims CMS-1500
Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received. copayment (copay)
Amount for which the patient is financially responsible before an insurance policy provides coverage. deductible
Reimbursement for income lost as a result of a temporary or permanent illness or injury. disability insurance
Health care coverage available through employers and other organizations. group health insurance
Three or more health care providers who share equipment, supplies, and personnel, and divide income by a prearranged formula. group medical practices
Mandates regulations that govern privacy, security, and electronic transactions standards for health care information. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Coverage for catastrophic or prolonged illnesses and injuries. major medical insurance
Cost-sharing program between the federal and state governments to provide health care services to low-income Americans. Medicaid
Reimburses health care services to Americans over the age of 65 and patients with End-stage renal disease (ESRD). Medicare
Federal legislation that expanded the Medicare and Medicaid programs. Omnibus Budget Reconciliation Act of 1981 (OBRA)
Designed to help individuals avoid health and injury problems. preventive services
Issues predetermined payment for services prospective payment system (PPS)
Performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. quality improvement organization (QIO)
Based on data collected from resident assessments, using data elements called the Minimum Data Set, or MDS, and relative weights developed from staff time data. Resource Utilization Groups (RUGs)
Payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services; physician work, practice expense, and malpractice insurance expense. Resource-Based Relative Value Scale system (RBRVS)
Process of the third-party payer recovering health care expenses from the liable party. subrogation
Who other than an insurance company administers health care plans and process claims, thus serving as a system of checks and balances for labor and management. third-party administrator (TPA)
Created by: Kcompleta