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CBCS Vocab Review
Hodgson Certification Review Chapter 3
| Term | Definition |
|---|---|
| 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
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