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Health insurance wk2
| Question | Answer |
|---|---|
| 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
Popular Health & Social Care sets