SBGR ALH 151 Week 4 Ch 17 Pearson's (2012 EK)
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| benefit period | period of time for which payments for insurance are available
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| capitation rate | predetermined amount paid to provider every month regardless of the number of times the patient is seen within the month
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| claim | written and documented request for reimbursement of an eligible expense under an insurance plan
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| closed-panel HMO | facility that is owned by the HMO and in which the providers are employees of the HMO
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| coordination of benefits (COB) | procedures to prevent duplication of payment by more than one insurance carrier; who pays first
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| crossover claim | patient claim that is eligible for both Medicare and Medicaid; also known as Medi/Medi
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| deductible | amount of eligible charges each patient must pay each calendar year before the insurance plan begins to pay benefits
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| exclusive provider organizations (EPOs) | combination of PPO and HMO concepts that allows the patient to select from a defined panel of providers
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| fee-for-service | set of fees for services established by a health care provider and paid for by the patient
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| fee schedule | schedule of the amount paid by a specific insurance company for each procedure or service subject to the managed care contract
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| formulary | specific to each insurance carrier, a list of medications that will be covered under that insurance plan
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| gatekeeper | a primary care provider who refers patients to other providers for services he or she cannot perform
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| health maintenance organization (HMO) | managed care plan in which a range of health care services provided by a limited group of providers (such as specified physicians or hospitals) are made available to plan members for a predetermined fee
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| integrated delivery system (IDS) | an arrangement in which provider sites have contracts with an insurance company
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| medical foundation | a nonprofit integrated delivery system
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| open-panel HMO | HMO in which health care providers are not employees of the HMO and do not belong to a medical group owned by the HMO
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| point-of-service plan (POS) | insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider
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| preauthorization | requirement to obtain prior approval for surgery and other procedures from the insurance carrier in order to receive reimbursement
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| preferred provider organization (PPO) | an insurance arrangement that requires the patient to use a provider under contract to the insurance company, which reimburses the provider at a discounted fee
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| premium | amount paid for insurance
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| prepaid plan | group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or capitated basis; also known as managed care plan
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| primary care provider (PCP) | gatekeepers provider who refers patients to other providers for services he or she cannot perform
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| referral | the process of sending a patient to or from another physician
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| self-referral | occurs when a patient chooses to see an out-of-network provider without authorization
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