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CBCS Vocab Review

Hodgson Certification Review Chapter 3

TermDefinition
adjustment remaining portion after the insurance carrier has met its financial responsibility and patient responsibility has been determined; must be written off of the account
allowed amount the maximum dollar amount the third party will reimburse a provider for a specific service
benefits health insurance coverage a member receives and the specific conditions under which the coverage is provided
CHAMPVA provides health care benefits to individuals with 100% service-related disabilities and their families
claims register log that lists information about each claim submission to an insurance carrier
closed panel HMO providers are either HMO employees or belong to a group that has a contract with an HMO, requiring them to care for any and all members assigned to the provider by the HMO
coinsurance patient's financial responsibility
commercial insurance carrier company that supplies health insurance coverage to individuals and /or groups
consolidated omnibus budget reconciliation act (COBRA) 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
covered expenses health insurance reimbursement for medically-related expenses
deductible patient's annual financial responsibility that must be met before the health care plan begins paying for health care costs
eligibility conditions members must meet to be eligible for coverage under a policy
employee retirement income security act (ERISA) federal law that sets minimum standards for self-insured health plans to provide protection for individuals who participate in these plans
exception provision of a policy that eliminates coverage
exclusion provision in a policy that denies coverage
explanation of benefits (EOB) itemized statement provided to members after a claim has been processed
explanation of payment (EOP) itemized statement provided to providers after a claim as been processed
express contract verbal or written contract in which a patient and a provider agree on certain terms or conditions before the care takes place
fee schedule list of maximum dollar allowances that apply under a specified contract
group policy health insurance plan purchased by an employer or organization and offered to the employees or members
health insurance claim number (HICN) number assigned to Medicare beneficiaries by the social security administration; consists of none digits and a numeric or alphanumeric prefix or suffix
health maintenance organization (HMO) managed care organization that provides low cost health care for its members in exchange for stringent guidelines and a limited choice of providers
implied contract contract between a patient and a provider in which no formal exchange takes place between the provider and the patient, either verbally or in writing
indemnity plans plans that allow members to choose their health care providers' members share in the cost of their health care with deductible and co-insurance payments; aka traditional plan
insurance plans plans that allow members to choose their health care providers; members share in the cost of their health care with deductible and coinsurance payments; also called a traditional health plan
insurance adjustments any remaining portion once an insurance carrier meets its financial responsibility and the patient responsibility is determined; portion must be written off of the account according to the provider's contract
legend provides the meaning of symbols, abbreviations, and terms used in explanation; aka key
Created by: tina.reynolds