Health Insurance ?s Word Scramble
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Question | Answer |
Health insurance is a contract between | a policy holder and an insurance carrier |
group insurance | a group of employees and their dependents are insured under 1 group policy issued to the employer |
personal insurance | an insurance plan issued to an individual |
pre-paid health plan | pre-determined set of benefits covered under one set annual fee |
health maintenance organization (HMO) | a managed care benefits plan that provides a wide range of medical services to idividuals enrolled - must have a primary care physician |
preferred provider organization (PPO) | like a HMO, but more flexiable - pay higher premiums - no primary care physician |
point-of-service plan (POS) | managed care plan that gives beneficiaries the option whom to see for services. |
Medicare Part A | covers hospital and hospice care |
Medicare Part B | covers medical expenses for Dr visits and lab tests |
Medicare Part D | covers prescription drugs |
advance beneficiary notice | a document provided to a medicare beneficiary by a provider prior to service being rendered letting the beneficiary know of their responbility to pay if medicare denies the claim |
medigap (medicare supplemental insurance) | this covers medical services that medicare denies (coinsurance) |
blue cross | covers hospital services |
blue shield | covers physician services |
assignment of benefits | reimbursement is directly sent from payer to the provider |
accept assignment | the provider agrees to accept what the insurance company approves as payment in full |
fee-for-service | a fee that is charged for each procedure or service performed by the physician |
fiscal intermediary | an insurance company that bids for a contract with CMS to handle the Medicare program in a specific area |
premium | the cost of insurance coverage |
deductible | out of pocket amount that must be paid annually |
coinsurance | percentage of cost of the covered services that a policyholder or a secondary insurance pays |
co-payment | a cost sharing requirement for the insured to pay at the time of service |
coding | the process of converting diagnoses, procedures and services into numeric and alphanumeric characters |
exclusions and limitations | conditions, situations and services NOT covered by the insurance |
pre-certification | to determine the patient's benefits and the maximum dollar amount that the insurance company will pay |
pre-authorization | a requirement for some health insurance plans to obtain permission for a service or procedure before it is done |
qualified diagnosis | a working diagnosis which is not yet established |
eligibility | the qualifying factor or factors that must be met before a patient receives benefits |
coordination of benefits (COB) | when 2 insurance companies work together to coordinate payment of the benefits |
peer review organization (PRO) | a state based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care |
civil monetary penalties law (CMPL) | law passed by the federal government to prosecute cases of medicaid fraud |
remittance advice | an electronic or paper-based report of payment by the payer to the provider |
patient's bill of rights | developed to promote the interests and well being of the patients and residents of the health care facility |
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