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HIT Chapter 4

Balance billing practice of billing patient for any balance left after deductibles, coinsurance, and insurance payments have been made.
Birthday rule informal procedure used to help determine which health insurance plan is primary when individuals are listed as dependents on more than one health plan
Cafeteria plan type of plan that deducts the cost of the plan from the employee’s wages before taxes for some insurance premiums, unreimbursed medical expenses, and child/dependent care expenses
CMS-1500 form the standard or “universal” claim form used to bill for all government and some commercial payers for outpatient and physician services
Coinsurance a type of cost sharing between the insurance provider and the policyholder where the patient and the insurance pay a specified percentage of the charges billed
Comprehensive plan a type of policy that combines basic and major medical coverage into one plan
COBRA-Consolidated Omnibus Reconciliation Act guarantees employees the right to temporarily continue their health benefits after quitting or being terminated from a job
COB-coordination of benefits determines the total benefits that primary and secondary insurance is allowed to pay. Both companies payments can not exceed 100% of the allowable charges
Deductible set amount that a patient must pay out of pocket before the insurance company will begin to pay
Disability insurance a type of insurance that provides weekly or monthly payment for lost income resulting from accidents or sickness or both that are not work related
Exclusions illnesses or injuries not covered by the health insurance policy
Group contract a contract of insurance made with a company, corporation, or other groups of common interest wherein all employees or individuals are insured under a single policy. Everyone receives the same benefits.
Indemnity(fee for service) the standard type of health insurance individuals can purchase, which provides comprehensive major medical benefits and allows insured individuals to choose any physician or hospital when seeking medical care
nonPAR-nonparticipating provider provider that has no contractual agreement with the insurance carrier and does not have to accept the insurance companies’ reimbursement as payment in full
Out of pocket maximum amount of medical expenses paid by the patient after which the UCR is paid in full by the insurer
PAR-participating provider a provider who contracts with a payer and agrees to abide by certain rules and regulations of that carrier
Policyholder the insured;individual whose name is on the policy
Preexisting condition physical or mental condition that existed before the effective date of an insurance policy
Premium specific amount of money paid by the insured to the insurance company in exchange for financial protection against loss
Created by: Alyshia