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Medical Billing17-31

Insurance Terms 17-31

Major Medical Type of insurance that does not covered primary care, but covers cost associated with significant illness or injury, such as hospitalization or surgeries
Managed Care Organization that provides comphrehensive health care services for plan participants at a fixed rate
Medicaid Provides health coverage for the categorically needy, a federal health cost assistance program
National Provider Identification Unique 10 digit number assigned to providers to identify them on a CMS 1500 claim form
Pre-authorization/Prior authorization Process of obtaining approval for a service through the the individual's insurance company by establishing that it is medically neccessary
Precertification Process of determind whether a service is covered under the insured person's plan
Predetermination Process of ascertaing the amount the insurance carrier will pay for a specific service
Preexisitng condition A diagnosed and treated health condition that the patinet had before obtaining insurance
Preferred Provider Organization (PPO) a plan allowing the insured person to select physicians, hospitals, and other health care services from an approved list issued by their insurance plan to proivde care at a discounted rate
Premium A dollar amount the insured person pays for insurance coverage
Prevailing fee The usual,customary, and reasonable fees of like providers in the same geographic area
Primary Care Provider (PCP) Physician contracted through a specific insurance plan to provide or to coordinate the care of all patients assigned through the insurance carrier
Third Party Provider The entity(insurance) that pays the second(provider) for the medical bills of the first party (patient, insured or patient) also known as the third party administrator
TRICARE Formerly known as CHAMPUS; health care benefits plans provided by the federal government, primarily for spouses and dependents of service men and women
Worker's Compensation Medical and diability insurance to cover employees in the event of a work-related injury, illness, or death.
Created by: d.holifield