Ch 15 Medical Insurance
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| EDI | Electronic Data Interchange
Involving the computerized transfer of health care information between 2 parties for specific purposes.
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| NPI | National Provider Number
# assigned to Providers by CMS for submitting insurance claims.
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| Supporting Claim Documentation | Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim.
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| Past Filing Limits | Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected.
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| Medicare | Federal Health Insurance program for people over age 65.
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| Medicare Part A | Hospital Insurance that is automatic if you receive Soc Sec benefits.
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| Medicare Part B | Fee-for-service, optional program that requires insured to pay income-based premiums.
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| Medicare Part C | Medicare Advantage Managed Care
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| Medicare Part D | Prescription Drug Coverage (limited)
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| WC | Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness.
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| Tri-Care | (formerly CHAMPUS) Government insurance program for active duty and retired military personnel.
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| CMS | Centers for Medicare and Medicaid Services
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| ABN | Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare.
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| Out-of-Pocket Expenses | Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers.
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| Primary Payer | 1st payer, usually responsible for more money or higher charge
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| Secondary Payer | MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose).
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| Physician Fee Schedule | The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient.
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| VOB | Verification of (Insurance) Benefits
Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt.
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| Pre-Authorization | Contacting the insurance company to obtain permission for a procedure.
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| COB | Coordination of Benefits
Determining the Primary / Secondary insurances
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| Co-Pay | Fixed $ amount that the patient pays
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| Co-Insurance | Fixed % that the patient pays
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| Deductible | Monetary amount patient must pay before insurance kicks in.
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| CMS-1500 | Uniform billing format used for medical claims.
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| Medicaid | MCD - Health benefit program for low-income patients. ALWAYS billed 2nd.
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| PCP | Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations.
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| CHAMPVA | Insurance through government for disabled veterans.
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