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Medical Insurance

QuestionAnswer
Renewable Provision A cancel-able policy grants the insurer the right to cancel the policy at any time and for any reason.
Optionally Renewable The insurer has the right to refuse to renew the policy.
Conditionally Renewable Policy grant the insurer a limited right to refuse to renew a health insurance policy at the end of the premium payment period.
Guaranteed Renewable Classification is desirable because insurer is required to renew the policy as long as the premium payments are made.
Non-cancelable The insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract.
Blue Cross- Blue Shield Independent, non-profit that contract with the hospitals and physicians to give prepaid health care.
CHAMPUS Civilian Health and Medical program of uniformed services, Government sponsored for active service members and those who die on duty.
CHAMPVA Civilian and Medical health program for veterans and their family.
CMP Federal legislature enrollment of medicare benefits into managed care.
EPO Member eligible for benefits only when they use services of limited network of providers.
Foundation for Medical Care Organization of physicians. Concerned with development and delivery and cost of health care.
All Medical records are confidential, except in what cases? 1)PT signed an authorization form to release info. 2)Worker's compensation cases. 3) When PT is suing, such as employer, who must protect himself. 4)When PT record are subpoenaed or there is a search warrant.
Preauthorization Form before they will approve certain hospital admissions.
Precertification Refers to discovering whether a treatment is covered.
Predetermination Discovering the max dollar amount the carrier will pay.
Adjuster Assists in settlement of claims.
Assignment Transfer of right to receive payment from PT to physician.
COB Coordination of Benefits- insurer takes into account another companies benefits before remitting payment.
Carrier Insurance company.
Deductible Amount insured must pay before policy will.
Exclusions Certain illnesses, injuries, benefits not included in policy.
Indemnity Benefits paid to insured.
Premium Periodic payment required to keep insurance effective
Subscriber One who belongs to insurance plan-usually finically responsible party.
Waiting Period Time that must elapse before indemnity paid.
Time Limit Period of time within which claim must be filled.
Eponyms Name for disease. "Parkinson's disease"
Dual Coverage Patients with two insurers.
Statue of Limitations 3 years for legal action.
Clean Claim Claim that was submitted with all pertinent info supporting documents, was processed and paid in timely matter. (60 days)
Dingy Claims Medicare contractor cannot process a claim for a service rendered. The claim is held until changes within the system allows.
Dirty Claims Claims with errors or those that require manual processing.
Rejected Claims Claims that require investigation. These claims may have coding errors, or clarification.
What action is done when PT misses an appointment? Bill sent for about $25-$50 for doctors time.
What type of info should not be faxed? STDS, drug or alcohol abuse/ treatment, HIV status.
How can instance claim be filled? Manual, in office, outside service bureau, telecommunications network, HCFA-1500.
Describe the process for an abstract of a medical record. 1) Agent must pay for the time and effort 2) signed release from PT 3)Only registered info.
What must be done prior to insurance companies creating medical record copies? 1) Copy make an appointment. 2)signed release from PT 3) only registered info
Billing for services not rendered. Fraud
Forging the medicare co-payment or deductible. Fraud
Excessive charges for services or supplies. Abuse
Billing Medicare beneficiaries at a higher rate. Abuse
Up-coding Fraud
Changing a date of service Fraud
Claims for services not medically necessary. Abuse
Requiring patients to pay for services not normally billed, such as telephone calls and/or prescription refills. Abuse
What does MCO stand for? Managed care organization
What does HMO stand for? Health Maintenance Organization
What does PPO stand for? Preferred Provider Organization
In what two ways does managed care pay for their participating physicians? Contracted fees and fixed prepayment (capitation)
In exchange for _________________, the health care provides benefits. Payment for medical services.
What is liability insurance? Covers injuries cause by the insured or that occurred on the insurer's property.
What are the three participants in an insurance contract and what is the definition? 1st party holders: policy holder. 2nd party: physician who provides medical services. 3rd party: who agrees to carry the risk of paying.
Created by: 100001204610760