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Health insurance wk2

QuestionAnswer
preauthorization determines medical necessity of the treatment
precertification determines if the treatment is covered by the insurance company
referral pre-approval or health care for an HMO member by a primary care provider
premium payment made by a member or subscriber for coverage under a policy usually on a monthly or yearly basis
pre-existing condition health problem that exists before enrolling in or becoming eligible for a health plan
co-insurance patients financial responsibility once all covered expenses have been reimbursed by the health care plan
co-pay specific amount the patient must pay the provider for each encounter also called the co-payment
EPO(exclusive provider network manage3d care organization that contracts providers to obtain services for members; members are restricted to using participating providers
coordination of benefits statement of how benefits are paid when the patient is covered by more than one insurance policy so the total amount of the bill is no exceeded
dependent individual who is covered by the insured's health insurance policy
benefits health insurance coverage a member receives & the specific conditions under which the coverage is provided
eligibility conditions members must meet to be eligible for coverage under a policy
(COBBA) consolidated omnibus budget reconciliation act federal act that gives former employees the right to continue their existing health care coverage under their employers plan for a limited time at the former employees expense
medical necessity determination by an insurance payer using evidence based clinical standards that as procedure or service is medically necessary
fee schedule list of maximum $s allowed for each procedure/ service under a specific contract
Created by: ashlyn.shaw