Understanding Health Insurance
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Insurance carrier | one who provides the benefits plan
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Group Insurance | employees and their dependents are insured under one policy
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Pre-paid Health Plan | pre-determined set of benefits covered under one set annual fee
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PPO | Preferred Provider Organization basically the same as HMO except you do not need to go to a provider within network .
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Indemnity Insurance | fee-for-service which services that are paid for are listed in the policy and payments are based on the fees physicians charge
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Personal Insurance | an individual insurance plan
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Relative Value Payment Schedules Method | use of relative value scales which assign a relative weight to services according to the basis for the scale.
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Preferred Provider plan | you can see a provoider outside of plan and you the patient is responsible to pay the higher portion of the fee.
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UCR | Fee schedule (Usual amount doctor charge), (Customary amount average charge by all providers) and (Reasonable amount submitted on claim...the lowest amount used as a basis for payment.
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RBRVS(Medicare's Resource Based Relative Value Scale Payment Schedule) | sum total of three elements: Work, Overhead and Malpractice
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Relative Value Payment Schedules Method | use of relative value scales which assign a relative weight to services according to the basis for the scale.
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RVP (St. Anthony Relative Value for Physicians) | Has no geographic adjustment factor or individual RVU component to calculate.
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Contracted Rates with MCOs | Physicians agree to provide services at a discount of their usual fee in return for a pool of existing patients.
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Capitated Rates | Physician provides a full range of contracted services to covered patients for a fixed amount on a periodic basis assuming the risk of the cost of providing the care.
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Medicare | Federal funded health insurance for persons 65 older, retired on SS benefit, spouse of a person paying into SS system, kidney donors.
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Pre-paid Health plan | pre-determined set of benefits covered under one set annual fee
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Medicare A | Hospital insurcance for Wage earner (upon retirement) also for aged and disabled.
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Medicare B | Supplementary Medical Ins. Coverage supp. to part A. Usually deducted from SS check.
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Medicare C | Addition coverage to Par A and Part B.
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Medicare D | Prescription Drugs...choice of plans to pay monthly premium.
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Medigap | Pay for medical services and items Medicare does not cover provided by federal govenment
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Medicaid | federal program administered by stat to provide medical assistance to the needy.
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Workers Compensation | Provides benefits to employees and their dependents for work related injury.
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Disability insurance | reimbursement insurance for income lost as a result of a temporary or permanent illness or injury.
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Liability insurance | insurance policy that coversw losses to a third party caused by the insured,
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Tricare | insurance for active duty and retired members of the armed forces and families.
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Champva | insurance for veterans and families.
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BlueCross/Blue Shields Plans | Blue Cross - covers hospital, outpatient care and home care. Blue Shield -covers physician, dental, outpaitent and vision care.
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Paper Claim | submitted on CMS-1500 form
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Electronic Claim | claim sent through a clearinghouse
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Clearinghouse | entity that receives transmissions of claims from physicians offices, separates the claims by carriers and performs softwre edits on each claim to check for errors.
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CMS-1500 universal claim form blocks | blocks 1-13 patient info. blocks 14-33 physician info.
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Basic Billing & Reimbursement Steps: | Collect patient info, verify ins, prepare encounter form, code diagnosis and procedures, review linkage and compliance, calculate physician charges, prepare claims, transmit claims, payer adjudication, follow up reimbursement/record retention.
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Consultation | Service performed by a physician whose opinion or advice is requested by another physican.
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Fiscal Intermediary | insurance company that bids for a contract with CMS to handle the Medicare program in a specific area.
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Explanation of Benefits | describes the services billed and includes a breakdown od how the payment is determined.
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Premium | cost of insurance coverage to keep a policy in effect.
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Deductible | Out-of-pocket amount that must be paid annually by policyholder before benefits will be paid by the insurance company.
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co-payment | cost-sharing requirement for the insured to pay at time of service.
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Coinsurance | a percentage of the cost of covered services that a policyholder or a secondary insurance pays.
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Coding | the process of converting diagnoses, procedures and services into numeric and alph. characters.
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Medical necessity | the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury.
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Exclusions and Limitations | conditions, situations and services NOT covered by the insurance carrier.
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Pre-certification | to determine coverage for a specific treatment under policy.
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Pre-determination | to determine the patient's benefits and dollar amount insurance will pay.
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Pre-authorization | a requirement for some health ins. plans to obtain permission for a service or procedure before it is done.
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Qualified diagnosis | a working diagnosis which is not yet established.
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Eligibility | qualifying factor or factors that must be met before a patient receives benefits.
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Coordination of Benefits | two insurance companies work together to coordinate payment of the benefits
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Encounter form | also called the superbill; it is a listing of the dignoses, procedures, and charges for a patient's visit.
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Itemized statement | statement of the patient's account history, showing DOS, detailed chargtes, payments, date the insurance claim was submitted and account balance.
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Peer Review Organization(PRO) | state based group of physicans working under government guideline to review cases and determine their appro. and quality of professional care.
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HIPAA(Health Insurance Portability and Accountability) | prevention of healthcare fraud/abuse of patients on Medicare and Medicaid.
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Nonparticipating physician | one who has no contract with the insurance plan.
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Participating physician | one who has a contract with a insurance and accepts what the plan pays for service.
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Group practice | two or more physicians and non-physician legally organized.
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Physicians Identification Numbers | State license #, EIN #, SS #, PIN #, UPIN #, PPIN #, group provider number.
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Policyholder | one who purchases the contrac
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Created by:
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