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Insurance Billing

YBI Insurance Proc Chaps 11, 12, 13

ABN Advanced Beneficiary Notice
CMS Centers for Medicare and Medicaid Services
copay copayment
EBP Employee Benefit Plan
EGHP Employee Group Health Plan
ERA Electronic Remittance Advice
ESRD End Stage Renal Disease
FPL Federal Poverty Level
MAC Medicare Administrative Contractor
MCO Managed Care Organization
MN Medically Necessary
MSN Medicare Summary Notice
SCHIP State Children's Health Insurance Program
SLMB Specified Low-income Medicare Beneficiary
SMI Supplementary Medical Insurance
SSI Supplemental Security Income
TANF Temporary Assistance to Needy Families
What is an agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment? ABN
What are supportive services other than routine hospital services provided by the facility, such as x-ray films and lab tests? Ancillary Services
What is a system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled? Capitation
Who are the aged, blind, or disabled individuals or families and children who meet financial eligibility requirements? Categorically Needy
What is a cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services? Coinsurance
What is a patient's payment of a portion of the cost at the time the service is rendered? Copayment
What are specific services and supplies for which Medicaid will provide reimbursement? Covered Services
What is a specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs? Deductible
What is a type of managed health care plan that combines features of HMOs and PPOs? It is offered to large employers who agree not to contract with any other plan. EPO
Who is one who controls patient access to specialists and diagnostic testing services? Gatekeeper
What is the oldest of all of the prepaid health plans? It provides a wide range of health care services with an emplasis on preventive medicine. HMO
What is a percentage limit on fees that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount? Limiting Charge
What is a generic term applied to a managed care plan? Managed Care Organization
What is a federally aided, state-operated and state-administered program that provices medical benefits for certain low-income persons in need of health and medical care? Medicaid
What is ther performance of services and procedures that are consistent with the diagnosis benefits for certain low-income persons in need of health and medical care? Medical Necessity
What are hospital benefits of a nationwide health insurance program for persons age 65 and older? Medicare Part A
What is medical insurance of a nationwide helath insurance program for persons age 65 and older? Medicare Part B
What is the Medicare Plus Choice plans that offer a number of health care options in addition to those available under Medicare Parts A and B? Medicare Part C
What is a stand alone prescription drug plan, presented by insurance and other private companies that offer drug coverage that meets the standards established by Medicare? Medicare Part D
What is it called when the primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before Medicare is sent a claim? Medicare Secondary Payer
Who are persons in need of financial assistance or whose income and resources will not allow them to pay for the costs of medical care? Medically Needy
Who is a physician who contracts with a HMO or other insurance company to provide servcies? This physician has agreed to accept a plan's payments for servces to subscribers. Participation Physician - par
What is a physician owned business that has the flexibility to deal with all forms of contract medicine and still offer its won packages to business groups, unions, and the general public? Physician Provider Group
What is a managed care plan in which members are given a choice as to how to receive servies, whether through a HMO, PPO, or fee-for-service plan? POS Plan
What is a type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider? PPO
Who is the physician who oversees the care of patients in a manged health care plan (HMO or PPO) and refers patients to see specialists for services as needed? PCP
What is the evaluation of a provider request for a specific service to determine the medical necessity and appropriateness of the care requested for a patient? Prior Approval
What are services requested by a specialist from another specialist? Tertiary Care
Created by: dsljulian
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